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Savoring the service: a mixed-methods study of Latine community health workers’ health promotion efforts
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Savoring the service: a mixed-methods study of Latine community health workers’ health promotion efforts
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Content
Savoring the Service: A Mixed-Methods Study of Latine Community Health Workers’ Health
Promotion Efforts
by
Elayne Zhou
A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF LETTERS, ARTS, AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(PSYCHOLOGY)
December 2024
Copyright 2024 Elayne Zhou
ii
Acknowledgments
Thank you to my coding team (Daniela, Marco, Jacob, and Violet) for helping me do justice to
the narratives our participants have entrusted us with. Thank you to Lyric for welcoming me onto
the team with open arms and for your guidance with these data. Thank you to Jessie and Stan for
taking a leap of faith with me during an uncertain time of transition and for cheering me on every
step of the way. Thank you to Gayla for your kind words, wisdom, and feedback. Thank you to
my family for your endless support and always creating a space to rest. Thank you to my partner,
Richard, for your faith in me, calmness, and steadfastness. And finally, thank you to my family
for patiently meeting me where I am always. I am so grateful!
iii
TABLE OF CONTENTS
Acknowledgments......................................................................................................................... ii
List of Tables................................................................................................................................ iv
Abstract ......................................................................................................................................... v
Introduction ................................................................................................................................... 1
Chapter 1: Methods....................................................................................................................... 9
Chapter 2: Results ....................................................................................................................... 24
Chapter 3: Discussion.................................................................................................................. 37
Conclusion................................................................................................................................... 43
References................................................................................................................................... 45
Appendix A: Savoring Task Protocol ......................................................................................... 53
iv
List of Tables
Table 1: Participant Sociodemographic Characteristics…………………………………………10
Table 2: Representative Quotes………………………………………………………………….26
Table 3: Descriptive Statistics and Correlations…………………………………………………36
v
Abstract
Background. Latine communities have long faced stark health inequities and systemic barriers
to accessing healthcare services. Community health workers (CHWs) serve as a key link between
patients and the often-daunting healthcare system, providing crucial health education and
support. Despite this important yet demanding role, little is known about CHWs’ personal
experiences of community health promotion and how they might draw upon their work for
strength and endurance. The present study explored the potential for relational savoring, a
procedure that elicits feelings of closeness and connection, to capture CHWs’ experiences of
community health promotion and shed light on the relationship between these experiences and
CHWs’ own well-being. Method. CHWs (n = 30) from California community health agencies
completed audio-recorded tasks in which they recalled and mindfully savored service provision
memories. Participants also completed questionnaires on burnout and psychopathology. Study
participation was part of a larger IRB-approved study. Transcripts were examined via inductive
thematic analysis. Exploratory bivariate correlations were conducted to examine associations
between qualitative code frequency and measures of burnout and psychological distress. Results.
Four themes were identified: Fulfilling Experiences, Sources of Resilience, Challenges of
Community Health Work, and Support Net. Exploratory analyses revealed significant
associations between qualitative codes related to interpersonal connectivity, intrinsic motivation,
and exceeding work expectations, and quantitative self-reported psychopathology and burnout.
Significance. The proposed study expands our understanding of key caregiving processes in key
community health workers to improve individual and group-level mental health outcomes in
Latine communities.
Key words: Lay health workers, Latine, community health, relational savoring, mixed methods
1
Introduction
Community health workers (CHWs) in low-income Latine communities embody a
striking paradox: as integral members of this underserved group, they are uniquely equipped with
the cultural understanding and intimate knowledge to foster conditions for optimal community
health. However, their vulnerability to poor health outcomes is also twofold, sharing similar
barriers and needs with their clients, which is further compounded by intensive service
responsibilities (Marquez et al., 2023). The COVID-19 pandemic has particularly disadvantaged
low-income Latine communities, which has had additional profound effects on the psychosocial
well-being of CHWs via the intensification of demand for CHWs’ services and destabilization of
an already overextended community health system (Marquez et al., 2023). Despite growing
interest in and research on CHWs and their effectiveness in promoting the health of others,
CHWs’ own well-being has been largely neglected (Rosenthal et al., 2011; Scott et al., 2018).
Additionally, what is currently known about how to promote healthcare workers’ resilience has
been driven by research on other healthcare providers, such as physicians and nurses (Cleary et
al., 2018; Kunzler et al., 2020). This limited research focus restricts the development of effective
interventions that could be specifically tailored to support CHWs. Guided by a strengths-based
approach, the present study delves into existing practices that help insulate CHWs from the wear
and tear of their demanding roles. This study aims to advance our ability to promote
improvements in health outcomes at both individual and community levels by illuminating the
experiences of the pillars of underserved Latine communities.
Addressing Latine Community Health Needs
CHWs support the health initiatives and overall well-being of Latine communities by
connecting various components of the community health system and ensuring its effectiveness.
2
The healthcare needs of Latine communities are indisputable. The California Health Care
Foundation reports that Latine people are overrepresented among residents living below the
federal poverty line, and are also more likely to report no usual source of healthcare, delayed
care due to cost or lack of health insurance, and more difficulty finding doctors than non-Latine
white Californians (California Health Care Foundation, 2021). It is no surprise, then, that Latine
Californians report poorer health than other racial-ethnic groups, including higher rates of
COVID-19 related infections and deaths (Centers for Disease Control and Prevention, 2020). In
response to these diverse health challenges, CHWs have mobilized to deliver targeted
interventions for a range of chronic health conditions in Latine communities including initiatives
from the Centers for Disease Control and Prevention (Centers for Disease Control and
Prevention, 2023). CHWs have also been instrumental in the successful recruitment and retention
of Latine populations in research studies to facilitate the development of more culturally
responsive measures and interventions (Johnson et al., 2013; Killough et al., 2022; Manzo et al.,
2018). Though support for the effectiveness of CHWs in improving health behavior and
outcomes is mixed (see Kaseje et al., 2024; Stacciarini et al., 2012; and Swider, 2002 for
reviews), various studies have demonstrated greater improvements compared to alternative
interventions (see Viswanathan et al., 2009 for a review).
The adaptability and flexibility of CHWs in responding to the varying needs of
community members allows for a personalized approach to address these challenges effectively.
However, capturing the resultant wide-ranging experiences of CHWs’ community services
becomes increasingly complex. For example, there is a lack of consensus surrounding the roles
and specific responsibilities of CHWs. Typically, the terms “community health worker” and
“promotoras [de salud]” are used interchangeably, which may obscure important nuances in the
3
essential community-engaged work they carry out. The groundbreaking Community Health
Worker National Workforce Study defines CHWs as community members that work, either paid
or unpaid, with the local healthcare system and that share important lived experiences and
identities with the groups they serve (Health Resources and Services Administration, 2007).
Importantly, it distinguishes promotores as a subset of CHWs, where promotores are those
community members who leverage their existing professional expertise and resources to
advocate for the betterment of their own community. While promotores are invaluable and have
received a deserved amount of interest from researchers and policy makers alike, they only
constitute a portion of the dedicated individuals embedded in community health systems who
form the spectrum of CHWs more generally. All CHWs actively serve the community through
different means, making them vital to the sustainability and smooth functioning of community
health systems.
An over-emphasis on front-line CHWs who are directly delivering health education and
promotion interventions inadvertently overlooks the broader range of individuals that interface
with the community at large to create conditions for health and well-being. Additionally,
focusing primarily on intervention delivery and outcomes may inadvertently apply an
incongruent medical model of health on CHWs who operate from a social model of health
(Chapman et al., 2016; Keane, Nielsen, et al., 2004). Said differently, rather than a singular focus
on the effects of modern medicine on health outcomes (medical model), CHWs examine and
address various social determinants such as social, cultural, political, and other environmental
factors that facilitate optimal health (social model; Hogan, 2019). The present study seeks to
widen the lens through which CHWs are examined and understand their experiences more
comprehensively. By doing so, we can broaden our conceptualization of the diverse
4
contributions of CHWs and develop strategies that support their individual well-being as well as
their capacity to care for the community at large.
Challenges Faced by Community Health Workers
Amidst the COVID-19 pandemic, CHWs have experienced heightened burnout and
psychological distress, grappling with unique stressors and demands that set them apart from
other essential frontline health workers (Marquez et al., 2023; Rahman et al., 2021; Wells et al.,
2021). Burnout is defined as a psychological phenomenon resultant from chronic interpersonal
stress within the workplace, bringing about unmanageable exhaustion, cynicism and
depersonalization, and a decreased sense of self-efficacy (Maslach & Leiter, 2016). Predictors of
burnout can be both individual (e.g., existing mental and physical health risks) and
organizational (e.g., caseload, work-life balance, organizational culture and support), while
social support may serve to buffer healthcare providers from work-related burnout (Meredith et
al., 2022). Similarly, long-term burnout has been linked to negative impacts on individual health,
personal relationships, and professional functioning (De Hert, 2020). The negative health
impacts of job-related burnout on mental well-being in essential frontline workers, particularly
during the pandemic, are well-documented (Ghahramani et al., 2021; Parandeh et al., 2022), yet
CHWs have received limited attention.
Prior to the pandemic, CHWs and the community health system were already
overstretched. Female CHWs shared with researchers the various challenges that emerged in
their work: work-life balance, gender power imbalance with male clients, emotional load, limited
English fluency, difficulty working with healthcare providers, managing conflict between
clients’ cultural beliefs and the community health agendas, and lack of transportation (Orpinas et
al., 2021). The pandemic has also worsened preexisting financial and psychosocial challenges
5
faced by CHWs, and the growing demand for support from their clients has further encroached
upon an already precarious work-life balance (Marquez et al., 2023). Despite these difficulties,
CHWs have embraced their expanded roles in the pandemic response and utilized the internal
and organizational resources available to them.
Though suggestions to address burnout in healthcare workers in the context of COVID19 have mostly excluded CHWs, these recommendations, such as interpersonal connections and
self-reflective practices, present a promising foundation for next steps (Leo et al., 2021). By
examining the distinctive bond between CHWs and the communities they serve, the proposed
study will shed light on strategies for mitigating poor health outcomes and enhancing the overall
well-being of these essential workers.
Resilience in Community Health Workers
Considering the demanding nature of healthcare, particularly within underfunded systems
responding to a global health crisis, it is crucial to investigate how CHWs safeguard their wellbeing and mitigate the risks of burnout and resultant adverse health outcomes. A recent
integrative review identified several key factors of resilience in hospital healthcare workers in
the pandemic, many of which are rooted in community and interpersonal connections including
moral purpose and duty, connections, collaboration, and organizational culture (Curtin et al.,
2022). Concerningly, additional studies found that resilience in nurses has decreased from prepandemic levels (see Baskin & Bartlett, 2021 for an integrative review). Yet, what is currently
known about resilience in healthcare workers is often limited by who is considered a “healthcare
professional.” While healthcare workers in hospitals and community health agencies may share
goals and face similar challenges in promoting overall health, CHWs occupy a markedly
different position in terms of both their duties and the specific settings they work in. Gaining
6
insights into resilience among various types of healthcare professionals serves as an initial albeit
insufficient step towards understanding the experiences of CHWs, who have been otherwise
neglected. Given that resources mobilized to improve resilience among healthcare professionals
have overlooked CHWs, very little is known about how CHWs may be best supported. In a
recent qualitative study conducted by Marquez and colleagues to identify the impacts of the
COVID-19 pandemic on promotoras/es (2023), various themes emerged, including social
disconnection, increased community needs, expanded service duties, and the emotional
challenges of representing a “community in pain.” Still, promotoras/es reported rewarding
experiences and a shared sense of “emotional unity.” These initial findings hint at the ways in
which promotoras/es may leverage their service experiences to navigate an unprecedented and
evolving landscape of care provision, though this focus does not include other kinds of CHWs.
The present study will explicitly focus CHWs’ narratives around what factors are important in
bolstering and supporting their well-being in underfunded healthcare systems.
Savoring, Social Connection, and Enhanced Positive Experiences
Relational savoring (RS), a procedure through which positive interpersonal experiences
are deliberately appreciated, may be a helpful tool in revealing CHWs’ conceptualizations of
social connection in their work. RS is an emotion regulation strategy related to general savoring,
which involves attending to, appreciating, and even enhancing positive experiences in one’s life
(Bryant & Veroff, 2007). With RS, the individual savors specific experiences of felt or provided
support and security within relationships (Borelli, Smiley, et al., 2020). For example, a person
could savor a time when someone said something supportive to them before they embarking on a
frightening challenge, or a time when they themselves comforted someone who was going
through a difficult life event.
7
RS can also be delivered in a guided intervention format. When delivered in this way, RS
protocols consist of a five-step reflective process that seek to promote the mindful enjoyment of
a particular relational experience: 1) sensory reflection, 2) emotion reflection, 3) meaning
making, 4) future-oriented reflection, and 5) internalizing the savoring exercise as a whole
(Borelli, Smiley, et al., 2020). RS intervention studies have reported outcomes such as improved
positive emotion, relationship quality, cardiovascular reactivity, and even adherence to COVID19 regulations (Borelli et al., 2015; Borelli, Bond, et al., 2020; Borelli et al., 2023; Doan et al.,
2023). The primary objective of RS is to cultivate connection and facilitate flourishing, a state of
optimal psychological well-being associated with resilience in the face of adversity (Ong et al.,
2006). Given its attachment focus, to date, RS has only been administered in the context of
individual relationships (e.g., mothers savoring experiences with their children, individuals in
long-distance romantic relationships savoring experiences with their partners). What is known
about challenges and successes of RS interventions, then, is limited to dyadic relationships only.
Thus, applying the concept of RS to CHWs’ relationships with a community, the focus of the
current investigation, is novel and can help shape future directions. In the present study, RS will
serve as lens through which I will examine the thought processes of CHWs around service
experiences and interactions with community members. Narratives generated from the RS
process can provide valuable insights into the salient experiences of CHWs and how they make
sense of their community service encounters during challenging times.
Proposed Study
By solely focusing on CHWs’ roles as facilitators of change in their communities without
considering the nuance and potential stressors inherent in their work, we risk overlooking crucial
factors that may impact both their own well-being and their ability to promote community health.
8
Therefore, the proposed study aimed to understand not only how CHWs engage with the
communities they serve but also how these interactions impact their own resilience in the face of
adversity. This work will advance our understanding of CHWs’ experiences of community
health promotion and help identify ways to support them more effectively.
The study sought to test four aims:
Specific Qualitative Aims
1. Use RS to investigate CHWs’ engagement with the community and identify salient service
experiences that are particularly impactful.
2. Characterize how CHWs derive value and meaning from service experiences (i.e., why
are these salient experiences impactful for CHWs?) .
Exploratory Quantitative Aim
3. Examine associations between RS qualitative codes and CHWs’ psychological distress
(i.e., if CHWs report more positive work experiences, do they also report less distress?)
9
Chapter 1: Methods
Participants
Participants included in the study (N = 30) are current employees of community health
agencies serving low-income Latine families. There was no eligibility criteria based on other
sociodemographic factors, and study participation was completed in either English or Spanish
depending on participant preference.
Recruitment
Participants were drawn from a larger, ongoing multi-site study approved by the
University of California, Irvine Institutional Review Board (#1596). Recruitment was carried out
via in person methods such as flyering and presentations through community agencies. Printed
and digital flyers and brochures were distributed to interested participants through their
community health agency employers. Our primary source of recruitment was through an ongoing
relationship with Latino Health Access, a community health agency serving the Santa Ana area
in California. Interested participants who contacted our lab completed a brief screening process
over the phone to ensure that they met inclusion criteria, and if eligible, were scheduled for a
virtual study appointment. The majority of the sample (n = 22) completed study participation in
Spanish, with the remaining participants completing study procedures in English.
All participants identified as Latine/Hispanic, and are largely of Mexican origin (n = 20);
one participant listed their country of origin as Venezuela, and the remaining participants (n = 9)
did not report country of origin. All recruited participants are California residents (see Table 1
for participant sociodemographic characteristics). Participants’ average age was 45.23 years old
(SD = 11.94 years) and the average number of years participants had been working as a
community service provider was 9.33 years (SD = 7.82 years). The majority of participants were
10
born outside of the U.S. (73.3%), female (96.7%), and had completed 12 years of education
(76.7%). Of note, no participants reported education beyond 12 years. Over half of the
participants reported their primary job duty as community outreach (56.7%). The median
household income of this sample was $40,000 - $44,999, which is substantially lower than the
most recently reported median household income in the state of California ($84,097) (U.S.
Census Bureau, n.d.). Still, our sample was above the 2023 poverty guideline for a 4-person
household in California ($30,000) (Office of the Assistant Secretary for Planning and Evaluation,
2023); the average Latine/Hispanic household is about 3.8 individuals (USAFacts, 2022).
Table 1
Sociodemographic Characteristics of Participants
Characteristic n %
Gender
Female 29 96.7
Male 1 3.3
U.S. Born
Yes 8 26.7
No 22 73.3
Marital status
Single 8 26.7
Separated 2 6.7
Divorced 5 16.7
Widowed 1 3.3
Married 11 36.7
Cohabitating 3 10.0
With children 22 73.3
Annual Family Income
Less than $5,000 1 3.3
$15,000 - $19,999 1 3.3
$20,000 - $24,999 1 3.3
$25,000 - $29,999 1 3.3
$30,000 - $34,999 3 10.0
$35,000 - $39,999 4 13.3
$40,000 - $44,999 6 20.0
$45,000 - $49,999 2 6.7
$50,000 - $54,999 3 10.0
11
$55,000 - $59,999 2 6.7
$60,000 - $69,999 1 3.3
$70,000 - $74,999 1 3.3
$80,000 - $84,999 1 3.3
$85,000 - $89,999 1 3.3
$100,000 - $149,999 2 6.7
Highest educational level
Less than 12 years 7 23.3
12 years 23 76.7
Community Health
Employment
Volunteer 2 6.7
Employed 13 43.3
Missing 15 50.0
Hours Worked
Part Time 7 23.3
Full Time 8 26.7
Missing 15 50.0
Primary Job Duties
Planning 4 13.3
Community outreach 17 56.7
Program delivery 2 6.7
Administrative work 3 10.0
Other 4 13.3
Procedures
The parent study utilizes a randomized controlled waitlist design, wherein all participants
are randomized into either an experimental group or a waitlist group following a baseline
assessment. Participation in the parent study occurs for a total of 5 hours across 7 time points for
the experimental group; CHWs complete a baseline assessment, weekly intervention sessions for
four weeks, a post-intervention follow up assessment, and a 3-month follow up assessment. All
study participation is completed online through the Qualtrics survey platform and via Zoom
conferencing software. More information about the full clinical trial can be found through the
National Institute of Health U.S. National Library of Medicine using ClinicalTrials.gov
Identifier: NCT05560893.
12
Participants, regardless of condition assignment, were included in the present study if
they had completed both the initial baseline assessment and the first intervention session. During
the baseline assessment, after providing consent, participants completed a battery of surveys
including those assessing experiences of burnout and psychological distress. The following
week, during their first intervention session, they completed a 30-minute RS task over Zoom
with research assistant interveners. Interveners engaged them in a guided memory reflection of
providing services to families in the local community. Participants were compensated $30 for
their participation at the baseline appointment and $25 for the first intervention session, which
were distributed, depending on participant preference, via Venmo, mailed physical gift card, or a
virtual gift card. Research assistant interveners also earned $20 for delivering the intervention
and were able to choose their compensation type; undergraduate research assistants were
compensated with research credit.
Measures
Demographics
At the baseline visit, participants reported on relevant sociodemographic characteristics
(previously reported in Table 1). A separate attempt was made to further collect details on
employment (employee or volunteer) and hours (full-time or part-time), but only half of the
sample responded and provided the requested information; thus, this information was not
included in analysis. Of the 15 participants who responded, the majority (86.67%) were
employed by their community health agency and worked full-time hours (53.33%).
Savoring
Participants completed a two-part relational savoring task with research assistant
interveners (see Appendix A for the protocol). The RS protocol was adapted for use with CHWs
13
from a script originally developed for use with caregivers (see Borelli, Smiley, et al., 2020 for a
detailed description of the original protocol and selections from the original script).
In part 1, interveners first engaged participants in a brief mindfulness exercise to set the
tone for RS; this step is not included in the analysis. Interveners then guided CHWs through
memory selection, with the goal of eliciting a memory of a time during which the participant
acted as a secure base or safe haven either for the community at large or for a specific
community member as part of their work. Interveners were instructed specifically to help CHWs
select a singular salient memory that did not evoke negative emotions. In the event that the
participant was unable to produce a memory with explicit secure base or safe haven content,
interveners were trained to highlight aspects of the support that the participant provided to the
community or community member that ultimately positioned the participant as a safe haven or
secure base for the individual.
In part 2 of the RS task (memory reflection), the participant was prompted to recall the
memory and savor various sensations, cognitions, and emotions tied to the salient experience
over the course of 10 minutes. Participants were instructed to verbalize their experience
throughout the guided reflection. During this portion of the RS task, interveners prompted
participants five times to attend to different features of the recalled experience. First, participants
recalled details of the memory. Next, they recalled emotions experienced and corresponding
physical sensations, and were asked to reexperience those sensations. Then, interveners
highlighted the secure base/safe haven role and encouraged participants to reflect on this ongoing
relationship with their community. Participants were then asked to practice a future focus,
extrapolating this experience to future engagement with the community. Finally, participants
14
mindfully reflected on the event in a non-directed manner and were encouraged to verbalize their
reflections.
Burnout
COVID-19 Specific Burnout. Burnout specific to COVID-19 was measured using the
10-item COVID-19 Burnout Scale (COVID-19-BS; Yıldırım & Solmaz, 2022). Respondents
reported on the frequency of experiencing various symptoms commonly associated with burnout
(e.g., emotional exhaustion, depersonalization, and reduced personal accomplishment) using a 5-
point scale from 1 – Never to 5 – Always. A total burnout score was calculated by summing
items, with higher scores indicating greater COVID-19 related burnout. The COVID-19-BS has
been found to demonstrate strong internal consistency (Cronbach’s α = 0.92) (Yıldırım &
Solmaz, 2022); in the current study, Cronbach’s α = 0.88. Good convergent validity has also
been previously demonstrated, wherein burnout was positively correlated with Coronavirus
anxiety (r = 0.51, p < 0.01); and good divergent validity, wherein burnout was negatively
correlated with resilience (r = -0.24, p < 0.01) (Yıldırım & Ashraf, 2023).
Work-related Burnout. Work-related burnout was measured via the 22-item
Maslach Burnout Inventory – Human Services Survey Form (MBI-HSS; Maslach et al.,
1997). The MBI-HSS contains three subscales: the 9-item occupational exhaustion (EE)
subscale (e.g., I feel worn out at the end of a working day), the 5-item depersonalization/loss
of empathy (DP) subscale (e.g., I’m afraid that my work makes me emotionally harder), and
the 8-item personal accomplishment (PA) subscale (e.g., I feel that I influence other people
positively through my work). Participants reported on the frequency of symptom occurrence
using a 7-point scale where 0 – Never and 6 – Every Day. Degree of burnout was assessed
using subscale scores (i.e., summed subscale items), with higher scores on EE and DP
15
indicating fatigue and negative attitudes towards clients, respectively, and lower scores on PA
indicating decreased self-efficacy and morale. Strong internal consistency has been reported
for the subscales, with Cronbach’s αs ranging from 0.72 to 0.90 with English and Spanishspeaking healthcare workers ( Forné & Yuguero, 2022; Gold, 1984; Iwanicki & Schwab,
1981). In the present study, internal consistency ranged from adequate to good for the EE
(Cronbach’s α = 0.87), DP (Cronbach’s α = 0.62), and PA (Cronbach’s α = 0.83) subscales.
Similarly, previous research has shown that 2-4 week test-retest reliability coefficients for
subscales were good, ranging from 0.53 to 0.82 (ps < 0.01) (Maslach & Jackson, 1981). The
MBI-HSS has also been previously shown to have good convergent and discriminant validity
(Champion & Westbrook, 1984).
Psychopathology
Participants reported on various domains of psychological distress using the 18-item
Brief Symptom Inventory (BSI-18; Derogatis, 2001). The BSI-18 assesses psychological distress
using three 6-item symptom scales: Somatization (e.g., nausea or upset stomach), Depression
(e.g., feeling blue), and Anxiety (e.g., spells of terror or panic). Respondents were presented
with a list of symptoms and then asked to report the degree to which the problems bothered them
over the past week (i.e., “How much have you suffered from…”). Participants then reported on
the frequency of related symptoms on a five-point scale: “None”, “A little”, “Moderately”,
“Frequently”, and “A lot”. Subscale scores were calculated by summing within each symptom
scale. A total score, or Global Severity Index (GSI), was also calculated from the sum of all
items. Higher scores indicated greater levels of behavioral and emotional problems.
Good internal consistency (Cronbach’s α’s ranging from 0.74 to 0.89) and test-retest
reliability coefficients (ranging from 0.68 to 0.84) were previously found (Derogatis, 2001). The
16
BSI-18 has been used with Spanish-speaking populations and has been administered to lowincome and immigrant Latine mothers in the Santa Ana area with good reliability (αs > 0.85)
(Arreola et al., 2022). In the present study, reliability statistics ranged from good to excellent for
GSI (Cronbach’s α = 0.95), and the Somatization (Cronbach’s α = 0.88), Depression (Cronbach’s
α = 0.90), and Anxiety (Cronbach’s α = 0.88) subscales. Preliminary validity information from
previous work is also promising; correlations between BSI-18 subscales with the Symptom
Checklist-90, from which the BSI-18 was originally derived, ranged from 0.91 to 0.96
(Derogatis, 2001).
Data Analytic Plan
Qualitative Data Analysis
Thematic Analysis
Background. To address the qualitative aims of the proposed study, we conducted a
secondary data analysis of qualitative data from savoring sessions. Specifically, we employed
reflexive thematic analysis (TA), which is an approach that allows researchers to extract,
investigate, and describe patterns and narratives from their data. Reflexive TA is known for its
theoretical and orientation related flexibility—that is, unlike other qualitative approaches that are
theoretically informed frameworks rather than adaptable methodology, reflexive TA allows for
either deductive (theory-driven) or inductive (data-driven) coding tactics (Braun & Clarke,
2021). Given the dearth of research on CHWs’ service experiences and well-being, we utilize an
inductive approach in the present study. Through inductive coding, or a ‘bottom-up’ approach,
themes are directly driven by and faithful to the raw data rather than being shaped by existing
theories or assumptions. An inductive and atheoretical approach is particularly valuable and
17
called for when researchers do not belong to community being studied and/or the community is
not well-researched.
Despite these approaches, it is impossible to disentangle TA from researchers’
proconceptions and biases, thus necessitating a constant commitment to establishing
trustworthiness that maximizes accountability, replicability, and rigor through each phase of TA
(Nowell et al., 2017). Trustworthiness can be assessed via the criteria of credibility,
transferability, dependability, and confirmability. Lincoln & Guba (1985) operationalized
credibility through member checking, testing the alignment between researchers’ interpretations
of the data with the participants’ own experiences. Transferability is the quality of
generalizability, thus what is required of researchers is being inclusive of information so future
researchers can determine how findings may transfer (Nowell et al., 2017). Dependability
indicates qualitative research conducted using an auditable, well-documented, and easily
followed process (Koch, 1994). Once the previous criteria are met, confirmability is then
achieved; the process through which findings are reached can be understood (Lincoln & Guba,
1985).
Braun & Clarke’s approach to reflexive TA includes six phases: familiarization, coding,
generating initial themes, reviewing and developing themes, defining and naming themes, and
writing up. Each phase as applied in the proposed study will be described in further detail in the
following sections. Note that, while each phase is distinct, researchers may vascillate between
phases or return to a previous phase as new information informs the process. To ensure
faithfulness to the participants’ experiences, we aimed to capture an essentialist or realist account
of the data. Essentialist/realist approaches “report experiences, meanings and the reality of
participants” (Braun & Clarke, 2006). Similarly, we identified themes at a semantic or explicit
18
level, where participant accounts and patterns are described and later interpreted as they are
written rather than seeking to identify and understand external forces that are contributing to the
presentation of the data.
Phase 1: Data Familiarization
Savoring sessions were transcribed using Trint, which uses artificial intelligence to
automatically transcribe audio and video content to text, and then manually reviewed for quality
control (Trint, n.d.). Trint is a secure platform, compliant with the European Union’s General
Data Protection Regulation directive. All data are stored on Amazon Web Services and
encrypted at-rest, meaning that data is converted into an unreadable format until it needs to be
accessed. Original recordings are automatically deleted within 30 days of upload on Trint.
Research assistants then reviewed and edited transcriptions for accuracy and ensured the removal
of any identifying information. A four-person coding team, bilingual in both English and
Spanish, was assembled. Coders identified their ethnic/racial background as the following:
Latino or Mexican-American (coder 1), Latino or Mexican immigrant (coder 2), Latina or
Ecuadorian (coder 3), and Colombian and Mexican (coder 4). The author self-identifies as a
second-generation Chinese American woman.
At the beginning of Phase 1, the lead author provided a training and overview of
qualitative research, planned phases of thematic analysis, and a brief introduction to the analysis
software. All phases were documented for auditability and were conducted in English. We used
Dedoose (Version 9.0.17), a user-friendly qualitative data analysis software, to collaboratively
analyze and process savoring transcriptions in real-time (Dedoose, 2021). In this phase, all
coders reviewed every transcript in the dataset in Dedoose. While reviewing each transcript,
coders engaged in a process called reflexive journaling. Coders added memos to each excerpt to
19
document their real-time reactions to the data; assumptions, perspectives, and/or biases; and their
thinking process to inform later formal coding and begin the process of brainstorming codes
related to the data. In Dedoose, each memo has a title and a description; titles serve as an
opportunity to summarize a reaction to the excerpt which is a starting point in developing codes.
Coders were instructed to read actively and aim to answer the following questions: 1) How does
this participant make sense of their experiences?; 2) What assumptions do they make in
interpreting their experience?; and 3) What kind of world is revealed through their accounts?
(Braun & Clarke, 2012).
At the end of this phase, the coding team met as a group to consolidate memos and
collectively process our initial reactions to the data, with the goal of producing “ideas about what
is in the data and what is interesting about them” (Braun & Clarke, 2006). Phase 1 lasted
approximately three months.
Phase 2: Initial Code Generation
During Phase 2, codes were assigned to the data. Braun & Clarke define codes as the
‘building blocks of analysis’ where a single word or concise phrase is identified and applied to a
data segment of interest to the research question(s) (Braun & Clarke, 2012). Codes allow
researchers to start to distill a large amount of data into more structured components such that
researchers are positioned to identify broader patterns. More specifically, at the beginning of this
phase, each coder produced some preliminary ideas around a possible code list. Coders were
trained on phase 2, and were provided general instructions on how to approach the data and what
constitutes a code. After creating a tentative code list and accompanying definitions (i.e., what
the code is and is not), the coding team independently coded three transcripts. Given that the
current analysis is guided by an inductive coding approach, the code list was purposefuly flexible
20
to accommodate the evolving coding process as new information is gleaned from the data. Thus,
after initial coding, the template was revised to refine coding categories and definitions in cases
of significant overlap or lack of clarity. Transcripts that were coded with the preliminary code
list were re-coded with the final code list.
During weekly meetings, the coding team engaged in consensus coding (Hill et al., 2005)
to resolve discrepancies on transcripts coded independently, reviewing disagreement as a group
and collectively determining the final code for each data excerpt of interest. Consensus coding or
having multiple coders review each transcript increases the credibility of the analysis. Together,
consensus coding and peer debriefing serve as forms of researcher triangulation where multiple
perspectives help minimize individual researcher bias and promote a more comprehensive
understanding of the data (Lincoln & Guba, 1985). Consensus coding was particularly necessary
and appropriate for the present analysis and coding team due to the makeup of the team—that is,
two of the four coders were interveners delivering the RS protocol (Coder 1 had administered RS
to 8 of the 30 participants and Coder 3 had administered RS to 7 participants). All consensus
coding processes and decisions were documented. Phase 2 lasted approximately three months.
Phase 3: Initial Theme Generation
After all relevant data excerpts were coded, the codes themselves were examined and
organized into themes. There is no one definition of what is sufficient to constitute a theme either
in number of codes subsumed by the theme or instances of recurrence of the theme across the
data set. It is broadly and flexibly defined as “captur[ing] something important about the data in
relation to the research question, and represent[ing] some level of patterned response or meaning
within the data set” (Braun & Clarke, 2006). The coding team was trained on the process of
arranging codes into themes before embarking on this phase.
21
Using the Dedoose software qualitative charts, the coding team reviewed a word cloud of
codes applied, a code frequency matrix, a code presence matrix, and a code co-occurrence
matrix. Across several weekly meetings, the coding team created and workshopped a list of
themes and related definitions, informed by the qualitative charts and their experience consensus
coding. To assist in visualizing how different codes cluster together or relate to others, a
preliminary thematic map was created through consensus. This phase ended with all codes
initially organized into themes. During weekly meetings, the coding team also begin
brainstorming with the first author around how themes fit together in the broader narrative. Phase
3 lasted approximately two weeks.
Phase 4: Review of Themes
Once a list of initial themes was produced, the coding team engaged in a refining process
by: 1) checking individual themes against coded data excerpts and 2) examining how well the
themes fit in with the dataset as a whole (Braun & Clarke, 2012). Importantly, the team ensured
that themes were both internally homogeneous and externally heterogenous—that is, the
rationale behind sorting codes into relevant themes was made clear (Patton, 1990). To that point,
it is important to acknowledge that one code (Gratitude from Clients) was deemed conceptually
relevant to two themes and thus was sorted into both Fulfilling Experiences and Sources of
Resilience. Through weekly meetings, the thematic map created in the previous stage was
revised and finalized to reflect any combined or further segmented themes, as well as the
relationships between themes to one another. Any decisions made that affected the hierarchy of
themes and assignment of codes were documented. Phase 4 lasted approximately two weeks.
Phase 5: Defining and Naming Themes
22
In this penultimate phase, my goal was to set the stage for generating the final report.
Once consensus was reached on theme names, organization, and definitions, a final table was
created of theme names, definitions, and representative data excerpts (translated from Spanish to
English if needed). The thematic map and representative codes were then presented to other
research assistants, graduate students, and staff that are familiar with the data but have not served
as coders for a second round of member checking and to receive feedback prior to presenting the
findings to the participants. Feedback on the order and presentation of the themes was
implemented and the thematic map was revised.
At the end of this phase, study participants were invited to attend a 1.5 hour focus group
at Latino Health Access, of which only a subset of study participants (n = 13) chose to attend.
During this meeting, the first author and coder 3 presented on the research findings and engaged
participants in a discussion to elicit feedback, in both Spanish and English. Three questions were
posed: What do you think of these themes?; Are you in agreement with our learnings?; and Are
there any changes that you would make to the themes? Participants in this focus group were
compensated $40 and provided a meal for their time. This step was an important step in
combatting the effects of researcher biases on the interpretation of the data; submitting results to
participants for feedback would allow the research team to do a final quality check and ensure
that the participants’ realities are well-represented in our report (Tobin & Begley, 2004). Phase 5
lasted approximately two weeks.
Phase 6: Generating the Final Report
In the last phase, all findings and logical processes were synthesized into the present
report. For a final time, the team engaged in peer debriefing through a presentation to members
of the research team that are not involved in the coding process but are intimately familiar with
23
the data through either data collection, management, and/or conceptualization. Pending review
from a committee of scholars, the report will then be distributed to the research team and
participating CHWs (in their preferred language).
Exploratory Quantitative Data Analysis
Prior to testing hypotheses, I examined the associations between participants’
sociodemographic variables and outcome variables. Conducting these analyses enabled me to
better understand the links between our qualitative data and sociodemographic variables and
could inform future work regarding potential confounds. Specifically, I conducted independent
samples t-tests to examine differences in psychological distress and burnout based on the
dichotomous categorical sociodemographic variables (country of birth – born in the U.S/not born
in the U.S.). In the case of multi-level categorical variables and ordinal sociodemographic
variables, non-parametric Kruskal-Wallis tests were conducted. Bivariate Pearson’s correlations
were performed to test associations between continuous sociodemographic variables and selfreported psychopathology and burnout.
Relationships between Qualitative Codes and Outcome Variables
To establish a preliminary association between CHWs’ experiences of serving the
community and measures of psychological distress, I performed a set of bivariate correlations
between qualitative code frequencies with a) burnout and b) psychopathology measures
(somatization, depression, and anxiety symptoms). All analyses were conducted in SPSS version
29.02.0.
24
Chapter 2: Results
Qualitative Results
A total of 2,175 data excerpts were included of 2,945 initial excerpts created during the
initial memoing process (Stage 1) and 18 codes were identified and applied 3,158 times. All
excerpts included in the analysis reached absolute agreement via consensus during the coding
process. Codes were sorted into a total of four themes: Fulfilling Experiences, Sources of
Resilience, Challenges of Community Health Work, and Support Net (see Figure 1 for thematic
map). Table 2 displays representative data extracts or quotes within each theme; Spanish quotes
were translated to English for the purposes of the present report. The results of the thematic
analysis are presented below in response to each of the research questions posed.
25
Figure 1
Thematic Map Displaying Themes and Respective Codes from Relational Savoring Transcripts
26
Table 2
Representative Quotes within Each Identified Theme Translated from Spanish to English
Support Net
(Indirect Impact, Direct Impact, Applying Unique Skills and Experiences, Going Above and Beyond)
• “I feel responsible that if I have, for example, my abilities to make crafts I feel
responsible that I have to teach people...and I feel I feel happy that I can teach others
my abilities, and that those people can then teach [others].”
• “And this is for me more than me helping fiscally-that is, directly to a person, for me
I feel that I am not helping but leaving something planted mhm right? And something
sown is that that person can be independent and not have to come all the time to the
promoter [Name] or the promoter [Name] or whoever to be able to resolve their,
their issues…”
• “Everything was like good for me, it was good like that, very gratifying, because I
felt good, useful because you helped a lot of people… But gratifying because you
helped a lot of people with–with food and with this financial help. There was–there
was a–there was a help. And–and they helped each other with their clients so that
they could open, so that they could eat. It went well and I liked it. I felt very useful at
that moment.”
• “Ah uh, since she speaks pure English, the one we are in, the one I put in school was
her husband…I sent him because he didn’t want to and I told him, ‘Yes, look you
have to do it’ and he said, ‘No’ that he will not want to do it. I told him, ‘No, yes, you
are going to do it because I am telling you to.’ And so I enrolled him, I sent him and I
am very proud because he is very consistent in his classes. He is on time to class,
does his homework, I mean, he is taking it like really, really, something like really
valuable to him. Very good, very good. It’s something very beautiful, mhm.”
Fulfilling Experiences
(Satisfaction with Community Health Work, Community Connections, Personal Benefit, Gratitude
from Clients)
• “Well, it is--it is-- personally I do have that satisfaction of-of saying or maybe I have
helped a bit, but I have contributed a bit to my community and also that I have
realized that- for example, our community is a community that needs a lot of help… I
think I can contribute so that the resources arrive to them, for them to take advantage
of the resources that exist, because when I say that there are resources for us to take
advantage of and for these to be utilized by those who really need it, right? That to
me--me. Well, yes, it creates a lot of satisfaction and at the same time like suddenly to
live, I think.”
• “Mmm, well generally uh we feel very supported. The truth is, in this country, in this
city, I am the only one from my family with my son, so practically they are my family,
all my memories are with them.”
27
• “I think that it is super good because every person that comes into my life impacts me
in some way, but at the same time I impact their lives. It’s like-like a mutual learning
[process] and the support is mutual, because when I lost my mom, they were with me,
they brought me flowers, umm they cooked for me so that I wouldn’t have to cook.
Umm, when they evicted me they would tell me, ‘This is your house, don’t worry.
Come here to the--to our house’s yard. We will set up a tent. You are not alone.’”
• “[My client said] ‘I attended the [event] and thanks to the [services] that you did
with us, you gave me the desire to live, I changed, I changed my way of thinking.' And
she thanked me very much, so that left me totally impacted like, there are others
memories, right, of other projects that I'm also involved in, [smacks lips] but this was
the one that left me the most impacted, and of-- of satisfaction and knowing that
perhaps those two hours that we met a week we were working on--on her without
realizing it and to change that way of thinking..."
Challenges of Community Health Work
(Sadness, Burnout, Helplessness, Overwhelm, Stress, Frustration, Worry)
• “If they got sick, they died because sometimes they arrived at the clinics very, the
people, very unwell, very unwell, I mean with those fevers and almost passing out
and [they] would arrive at the clinics infected people and a lot of people. Even
though it was painful because a lot of people started to lose their family members.”
• “To the point where we can put our limits ourselves, because we have to take care of
our integrity, right? We cannot risk our lives for other people. And even more if
[they] don’t want to receive help. So yeah…until now I don’t see that-that we play an
important role or that-that our job is totally recognized because it is not recognized.”
• “Sometimes, you know, when you feel like, okay, you’re maybe not doing enough for
someone and you kind of feel like I couldn’t help them maybe mhm….Like, I just
there was no help for this person. So I had to just leave them in the middle of mhm
their situation.”
• “I imagined economically [they] will use a lot of help and that was more like my-my
worry if you can say that, because I said, how will we help this family?...it will need
we will need a lot of help with this family economically and more, not-not
economically, emotionally too, but also because I saw that they were it looked like
they were very humble, economically like not—not too stable.”
• “Sometimes it’s a little, we can talk with a lot of people to help [them] but really
what [you] are doing is how we feel at the same time we are helping and sometimes
we ask ourselves mhm ‘how do I feel?’ Because these people don’t ask me how do I
feel. Maybe I have problems, I have to bring out [my] joy to the people so they don’t
see me sad, nor frustrated, or sometimes I have depression problems but I have to
face the community because the community too, well [they] go through worse things
that oneself.”
• “I’m very critical…not satisfied nor proud mhm I will feel proud when, when less
youth are criminalized, [when] I see that the system is starting to do something for
the youth.”
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• “Well, when um—when I started [Service] I thought ‘What will I teach them, no?
What will I tell them? What will I talk about? Um, what topics do I have to study?
Mostly I thought like um like more like arriving and teaching like a class and that
[they] write [things] down, no?... so I had those those thoughts of doubt, no? Of—of
fear that I will not be able to.”
Sources of Resilience
(Gratitude from Clients, Inner Drive, Relatable Experiences, Spirituality)
• “Well yes I felt happy like no, no, I don’t want to cry because it tickled my stomach of
happiness and of surprise. And it’s me and happiness. Happiness that someone came
to my door and brought me flowers…I was all happy and with everyone that would
want to talk to me I would tell them ‘this happened to me’ and that day I would tell
them the story, but yes I go [feeling] well, I liked it.”
• “Well you see, in that moment my goal was to fulfill the need of the lady, which was
the vaccine, mhm mhm, so I focused on that to see in what way I could help her, how
I could help her, because I did not want to let her down, right right, I didn’t want her
to feel like--like--feel insecure with me and later I be like ‘nothing can be done’, no
no no, I was very focused in being able to satisfy her need.”
• “Well this is a success for us, because we were there at some moment in our lives,
and I think that is the success of promotoras. The ‘oh shoot, me too, I can act and
help.’ And you do it with all your heart. Of course. It’s the experience, then, that you
understand the interconnectedness because of the [shared] experience…”
• “...I always try to always give thanks to God because I say ‘Yes, wow, I don’t know
how it happened, but I did it and thanks to God that gave me the opportunity to do it’,
right? Because I always thought of saying ‘Father, I have this and that type of
responsibility that I carry, but without your help I will not be able to do it’ and I’m
praying that everything goes well.”
29
(RQ1a) How do Community Health Workers Engage with the Community?
CHWs promote the social model of health through various means–that is, they work to
create and enhance the conditions for optimal health by influencing their clients’ immediate and
broader environments.
Support Net. CHWs form a support net for their clients, providing a web of resources for
their community. Much of this support is achieved through acting as a reliable source by meeting
clients’ needs. For instance, CHWs provide funds to assist clients facing eviction, host a regular
community food bank, provide emotional support for clients, and connect clients to necessary
healthcare or legal services. CHWs described witnessing the fruits of their labor and the
immediate impact of their efforts on their clients’ lives and wellbeing. Several specifically noted
the importance of cultivating independence and self-reliance in their clients so that they may help
themselves in the future. Many CHWs also expressed a desire to “plant a seed” by empowering
their clients to help others in the community, and in essence, compounding their own impact by
positioning their clients as agents of further change; in fact, several CHWs recalled seeing their
former clients joining the community health “support net” themselves by volunteering or sharing
resources with others in need. One CHW described the value of acknowledging impact no matter
how big or small, describing it as a “granito de arena” or grain of sand. Regardless of the type of
services provided, CHWs often applied their own unique skills and experiences developed
externally to their work to find creative solutions to community needs. For example, CHWs
incorporated their artistic abilities, listening skills, or community organizing in the services they
provided.
Perhaps most striking was the CHWs’ recounting of experiences where they improved the
lives of their clients above and beyond their job description or the immediate presenting need—
30
that is, working beyond their scheduled hours, sustaining long-term friendships with clients, and
supporting community members in a manner that exceeded professional or formal expectations.
A particularly illustrative example is the below instance, translated from Spanish to English. In
this instance, a CHW, invested in the long-term success and well-being of both her client and the
client’s family, proactively enrolled her client’s husband in English classes, and continued to not
only provide encouragement but also keep up to date with his progress.
“Ah uh, since she speaks pure English, the one we are in, the one I put in school was her
husband…I sent him because he didn’t want to and I told him, ‘Yes, look you have to do it’
and he said, ‘no’ that he will not want to do it. I told him, ‘No, yes, you are going to do it
because I am telling you to.’ And so I enrolled him, I sent him and I am very proud
because he is very consistent in his classes. He is on time to class, does his homework, I
mean, he is taking it like really, really, something like really valuable to him. Very good,
very good. It’s something very beautiful, mhm.”
(RQ1b) What Service Experiences are Particularly Salient and Impactful?
Most commonly, CHWs spoke about the benefits and positive effects that they experienced
as a result of their roles in the community. However, community health work is not without its
challenges. CHWs also described various struggles resulting from the demands of their position,
though this was the “thinnest” or least represented of the identified themes.
Fulfilling Experiences. CHWs frequently described, with emotion, the sense of fulfillment
they derived from engaging with their community clients. CHWs described satisfaction with
what they may achieve through their unique role (i.e., their [potential] contributions to the
community at large)—that is, for some, the position they hold contributes to a realization of
purpose or a meaning-making process. Additionally, several CHWs described satisfaction with
31
the work environment and their team, specifically describing collective efforts with coworkers
and community members to make a lasting impact on their broader community through
programming and advocacy. Relatedly, one of the most prevalent meaningful experiences
described by CHWs was the sense of felt connection that they shared with community members
via trust building, providing CHWs a strong feeling of belonging as well as the opportunity to
provide a safe space for clients.
CHWs also noted other personal benefits that they perceived resulting from the position,
including monetary support, though for some the financial incentive was a bonus to the broader
fulfillment they experienced. Efforts were often mutually beneficial and CHWs described not
only growing professionally through the lessons learned through working with the community
but also receiving support themselves in times of need. For example, in the quote below
translated from Spanish to English, a CHW describes the bidirectional caregiving and
carereceiving they have engaged in with their community clients.
“I think that it is super good because every person that comes into my life impacts me in
some way, but at the same time I impact their lives. It’s like-like a mutual learning
[process] and the support is mutual, because when I lost my mom, they [referring to
community members served] were with me, they brought me flowers, umm they cooked
for me so that I wouldn’t have to cook. Umm, when they evicted me they would tell me,
‘This is your house, don’t worry. Come here to the--to our house’s yard we will set up a
tent. You are not alone.’”
Often, a particularly salient benefit that CHWs received from their clients was in the form
of gratitude. The majority of CHWs described moving displays of appreciation that they received
32
from their clients, whether verbal or physical, which served as tangible reminders of the impact
that they had made through their work.
Challenging Experiences with Community Health Work. Challenging or negative
experiences with community health work appeared somewhat unexpectedly during the RS
process. CHWs empathized with the suffering, pain and loss experienced by community
members, particularly during the pandemic. Moreover, CHWs described feeling emotional and
occupational fatigue, wherein they expressed exhaustion, dissatisfaction with work
responsibilities, and experiencing devaluation of their work, such as the below example
translated from Spanish to English.
“To the point where we can put our limits ourselves, because we have to take care of our
integrity, right? We cannot risk our lives for other people. And even more if [they] don’t
want to receive help. So yeah…until now I don’t see that-that we play an important role or
that-that our job is totally recognized because it is not recognized.”
Some CHWs expressed a sense of lack of control or helplessness in being able to fully
resolve clients’ problems due to insufficient resources or funding. Similarly, CHWs shared a
feeling of being overwhelmed due to the discrepancy between supply and demand. A few CHWs
expressed some nonspecific stress associated with community health work and the challenge of
serving a struggling community while also themselves struggling with unmet needs, such as the
below example translated from Spanish to English.
“Sometimes it’s a little, we can talk with a lot of people to help [them] but really what
[you] are doing is how we feel at the same time we are helping and sometimes we ask
ourselves mhm ‘how do I feel?’ Because these people don’t ask me ‘how do I feel?’ Maybe
I have problems, I have to bring out [my] joy to the people so they don’t see me sad, nor
33
frustrated, or sometimes I have depression problems but I have to face the community
because the community too, well [they] go through worse things that oneself.”
Some CHWs expressed frustration with and anger around systemic barriers or challenges
that the broader community was facing. Additionally, several CHWs demonstrated a lack of selfefficacy or appeared preoccupied about their ability to meet their clients’ needs. Still, many of
the challenges faced by CHWs appeared to stem from ongoing larger structural issues which
actively complicate and impede their ability to meet community needs, which I would like to
intentionally emphasize.
(RQ2) How do Community Health Workers Derive Value and Meaning from Service
Experiences?
Sources of Resilience. Expressions of appreciation and gratitude from clients, while a
source of fulfillment, also appeared to contribute to CHWs resilience and emotional strength.
Community connections are intertwined with CHWs’ longevity and motivation. Many CHWs
reported a sense of recognition of or identification with their clients’ experiences; some
explicitly described memorable clients as reminders of their past selves or of a loved one,
reflecting on shared needs and struggles as an impetus for action.
“Well, this is a success for us, because we were there at some moment in our lives, and I
think that is the success of promotoras. The ‘oh shoot, me too, I can act and help.’ And you
do it with all your heart. Of course. It’s the experience, then, that you understand the
interconnectedness because of the [shared] experience…”
Indeed, several CHWs expressed intrinsic desires or an inner drive to help others, with
some describing a past history of helping or volunteerism prior to working at their current
agency. Finally, a number of CHWs made references to their religious or spiritual faith,
34
specifically in terms of relying on and trusting in their faith to guide them through difficult
decisions or challenging times, as well as considering the work and opportunity to aid their
community as God-given.
Quantitative Results
Preliminary Analyses Between Sociodemographic Variables and Outcome Variables
Independent samples t-tests were performed to examine if there were differences in
reporting of psychological distress and burnout based on whether participants had been born in
the U.S. No such differences were uncovered for any variable (ps > 0.05). In the case of the
multi-level categorical variable, primary job duty, and the ordinal variable, income, nonparametric Kruskal-Wallis tests were conducted, again revealing no significant differences
between groups for any variables of interest (ps > 0.05). Lastly, bivariate Pearson’s correlations
revealed no significant correlations between continuous sociodemographic variables (education
and years worked as a CHW) and either psychopathology or burnout.
Exploratory Quantitative Aim: Examining Associations between Qualitative Codes and
Outcome Variables
Bivariate Pearson’s correlations were performed as a preliminary assessment of
relationships between indicators of psychological distress, burnout, and qualitative code
frequencies (see Table 3). First, indicators of psychological distress and burnout were positively
intercorrelated: COVID-19 related burnout was positively correlated to symptoms of
somatization (r = 0.46), depression (r = 0.41), and anxiety (r = 0.40) as well as emotional
exhaustion (ps < 0.05), though it was not significantly correlated to depersonalization or personal
achievement. Similarly, only one dimension of occupational burnout, emotional exhaustion, was
correlated (positively) with somatization (r = 0.44), depression (r = 0.44), and anxiety (r = 0.42)
35
symptoms (ps < 0.05). Regarding relationships between qualitative code frequencies and
psychological distress, significant correlations emerged only for three codes: Community
Connections, Going Above and Beyond, and Inner Drive. Community Connections was
negatively correlated with anxiety symptoms (r = -0.44, p = 0.02) and with the depersonalization
dimension of occupational burnout (r = -0.38, p = 0.04). Going Above and Beyond was
positively related to the personal achievement dimension of occupational burnout (r = 0.36, p =
0.05). Lastly, Inner Drive was negatively correlated with anxiety symptoms (r = -0.37, p < 0.05).
Table
36
3
Descriptive Statistics and Correlations for Indicators of Psychological Distress and Qualitative Code Frequencies
37
Chapter 3: Discussion
The current study employed a mixed-methods approach to investigate CHWs’ experiences
of serving their community clients, and how various experiences may be differentially related to
CHWs’ own well-being. Importantly, I uniquely center the study focus on CHWs’ individual and
collective experiences rather than considering CHWs as a means to an end (i.e., effectiveness in
intervention delivery and promoting community health outcomes). Employing RS as a tool to
understand how CHWs engage with their client community and make meaning from these
experiences, we identified four qualitative themes (ordered here by thematic “thickness” or most
to least represented): Fulfilling Experiences, Support Net, Sources of Resilience, and Challenges
of Community Health Work. Additionally, preliminary relationships were observed between
qualitative codes regarding interpersonal connectedness, intrinsic motivation, and exceeding
work expectations, and both work-related burnout and anxiety symptoms. Findings bolster our
understanding of community caregiving processes and their role in the lives of CHWs, further
illuminating how community health work may be linked to CHWs’ well-being and work-related
longevity.
Qualitative Findings
Our study was the first to utilize RS as a method of uncovering the intricate and dynamic
relationships between CHWs and the communities that they serve; however, several of our
findings complement the minimal existing literature on CHWs. Findings indicate that 1) CHWs
engage with the community by comprising a support net for a community in need, 2) CHWs are
particularly impacted by both fulfilling (e.g., personal benefits via professional development,
tangible impact, and community connections) and challenging experiences (e.g., sadness,
emotional burnout, and overwhelm) in their work, and 3) CHWs derive strength and resilience
38
from various intrinsic (e.g., inner motivation, religiosity) and extrinsic sources (e.g., shared or
relatable experiences) in striving to benefit their client community. Past qualitative work with
promotoras/es reported similar findings around professional transformation, socio-emotional and
organizational challenges, and commitment to community health work by way of close
interpersonal relationships (Gutiérrez et al., 2021; Orpinas et al., 2021). Despite the alignment in
many of our findings, the current study contributes an added layer of understanding of
community health work, as past research on CHWs has to our knowledge exclusively centered
the experiences of promotoras/es, who are typically primarily engaged in program delivery, but
are not representative of all individuals who work as CHWs to improve community well-being.
Using RS as a way to share their narratives around community health promotion, CHWs
illustrated several of their existing strengths as well as areas for further support. First,
relationships are paramount to successful community health work. CHWs find both internal (e.g.,
within the organization) and external relationships (e.g., with clients and collaborators) to be
rewarding and beneficial. Unsurprisingly, when interpersonal and organizational support is
lacking, then CHWs find it difficult to engage in the work and meet community needs. While
CHWs form a support net for others, they themselves require emotional and financial support
nets that can catch them when they are depleted from the demands of community health work.
These findings have important implications for programming and structure within community
health agencies. In addition to increased financial compensation for CHWs, community health
agencies should consider the benefit of introducing peer support models for all CHWs, regardless
of their primary job duty or volunteer status. Programs such as RS which extend CHWs
experience of meaningful and rewarding experiences and thus, possibly the existing benefits of
the work may also warrant further consideration. Second, CHWs draw from various sources of
39
resilience; thus, different aspects of community health work are salient to different CHWs.
Taking a personalized approach to fostering resilience in CHWs from the beginning of their
work with communities may contribute to their longevity in and satisfaction with the role.
Identifying the sources of motivation for each CHW (e.g., spirituality, interpersonal connections,
values around contributing to or helping their community) and regularly creating space for
CHWs to deliberately access and experience those values may also increase their motivation or
job satisfaction in the long term. Third, it is important that CHWs perceive that their work is
making a tangible impact in their immediate and broader community. Agencies are encouraged
to regularly acknowledge the accomplishments of individual CHWs and as a group—
specifically, agencies may want to emphasize how the contributions of each CHW, regardless of
the division of their time and labor, further the grander mission of the social model of health in
the community. In sum, our takeways in analyzing CHWs’ experience of community health
promotion illustrate the importance of proactively investing in CHWs wellbeing.
Exploratory Quantitative Findings
In the present study, preliminary associations were found between several qualitative code
themes and not only burnout (job-related construct) but also mental health. With greater
applications of the code Community Connections, wherein CHWs describe close bonds and
relationships with individual clients and/or broader client community, CHWs reported
experiencing less anxiety and depersonalization (i.e., interpersonal disconnection and relatedly
reduced empathy). These findings complement previous research identifying interpersonal
support as a protective factor against healthcare workers’ anxiety (Fang et al., 2021) and a
deterrent to the deleterious effects of burnout in healthcare workers (Ruisoto et al., 2020; Stanley
& Sebastine, 2023; Huang et al., 2023). As such, while CHWs are a key source of community
40
caregiving, they too need and benefit from nurturance, and the care they receive may have
important ties to the care they can provide. The current study assessed these associations at a
single time point but these preliminary findings point to the necessity of exploring bidirectional
associations between these experiences.
Additionally, the more the qualitatively reported experiences of Inner Drive, or internal
motivation to carry out CHW and meet client needs, the fewer the anxiety symptoms reported.
Existing work has similarly uncovered associations between intrinsic motivation in preprofessional medical students and fewer symptoms of anxiety and other internalizing disorders
(Terzi et al., 2022). However, our study is the first to our knowledge to explore this relationship
in CHWs or professional healthcare workers. Finally, with more instances of Going Above and
Beyond, where CHWs proactively or intentionally exceeded their job description to improve
their community well-being, CHWs reported feeling greater levels of personal achievement. Yet,
past work has shown that workplace factors such as demanding workloads and long hours have
been identified as risk factors for burnout (Bouskill et al., 2022), with reduced personal
achievement often serving as a hallmark for occupational burnout. Thus, while this finding may
be somewhat unexpected, considering the intentionality and autonomy related to engaging in
additional work may be important in making sense of this relationship. In fact, existing research
has linked workplace empowerment and autonomy with decreased intention to resign in
healthcare workers (Kim & Stoner, 2008), decreased burnout (Orgambidez & Almeida, 2019),
and increased job satisfaction (Larabee et al., 2003). In this way, the experience of burnout and
psychological distress in relation to community health work, which is distinct in both its working
model of health as well as role demands, may be multifaceted and important to further explore.
Limitations and Future Directions
41
While the present study is poised to expand our understanding of how CHWs not only
serve but also draw strength from their client community, our findings should also be couched in
several limitations. First, though a sample size of 30 is comparable to typical sample sizes in
qualitative research (Clarke & Braun, 2013), it does limit the generalizability of our exploratory
quantitative findings. Moreover, only one participant identified as male, which means our sample
is limited in its representativeness of varied CHW experiences. This is particularly true given
gendered perceptions of the role that contribute to the underrepresentation of men in the CHW
workforce and could have implications on belongingness of male CHWs (Villa-Torres et al.,
2015). However, it is important to note that the low percentage of male CHW participation in our
study aligns with state-wide trends—findings from a recent report from the California Health
Care Foundation reported that the majority of CHWs in California are women (Chapman et al.,
2022). Additionally, our sample of CHWs were situated in California, where as of the 2020
Census, Latine or Hispanic identifying individuals make up the largest racial or ethnic group in
the state, which may not represent the experience of CHWs in states with fewer Latine
individuals. Further, even within a single state, CHW experiences may differ depending on the
demographic makeup of their client community, resources of their community agency and
neighborhood served, and the policies impacting different areas. In addition to the limited sample
size, I was not able to evaluate differences in responses based on factors that could be important
to evaluate, including hours worked (e.g., full-time, part time), work status (volunteer, paid), or
legal status, due to the structure of our data collection, the sensitivity of the questions and the
preferences of our community partners, which could affect the conclusions drawn and would be
important to explore in future research.
42
Second, the present study is a secondary data analysis of qualitative data and thus did not
utilize a qualitative interview guide intentionally devised to answer the specific research
questions of the current study. However, RS is a useful tool by which researchers were able to
gain insight into the close relationships and relationship processes that CHWs share with their
client community and tap into important personal and community narratives. Still, the present
study took a number of measures to meet suggested standards for conducting secondary data
analysis of qualitative data regarding clarity (i.e., between the present and parent study) rigor
(e.g., trustworthiness via documentation, peer debriefing, member checking, and including
research team members from the parent study), and delineating limitations (Ruggiano & Perry,
2019). Third, two members of the coding team had served as interveners in the parent study,
delivering the RS protocol to 50% of the participants included in the study, which may have
introduced bias into the coding process. While including research members from the parent study
is actually recommended in secondary data analysis of qualitative data (Ruggiano & Perry,
2019), I nonetheless took precautionary steps to reduce coder bias as much as possible. To
address this concern, the decision was made to conduct coding via consensus between all coders
rather than to divide coding and conduct inter-rater reliability analyses. Peer debriefing and
member checking processes also served to address coder bias. Still, potential coder bias should
be considered in the interpretation of the study findings.
While future research should be guided by research findings, it is equally if not more
important to also ensure research is addressing and responding to community needs. In the case
of the current study, I received important feedback and suggestions for research directions from
our focus group of participants during the final member checking process. Though the present
study explicitly adopted a strengths-based perspective, CHWs emphasized that they did not want
43
a focus on resilience to water down their yet unmet and overlooked needs, particularly with
regards to systemic and structural barriers faced. Specifically, CHWs called for a “denormalization of the way [we] live” regarding unfair compensation and challenging living
situations. One CHW stated “de buena gente no vives” or that simply being a “good person” is
insufficient to survive and thrive. Rather, CHWs urgently need greater mental health support as
well as the legitimization of their expertise via their role as CHWs. Specifically, they described
that, despite “pouring their souls” into their demanding roles, the lack of recognition and
dignification of their experience as CHWs as well as other past experiences (e.g., foreign
degrees) served as a barrier to employment and working in certain clinical settings. Yet, like
many other CHWs in California (Kissinger et al., 2022), CHWs participating in the focus group
strongly opposed efforts by the state to move towards certification of CHWs, stating that
certification will become a further barrier for CHWs’ own work and employability. Notably,
CHWs made explicit that their calls for fair compensation and recognition of their experience
also extend to research partnerships and the growing interest from institutions in CHWs.
Conclusion
Though the results highlight important factors relevant to individual resilience and workrelated longevity, I would be remiss to paint individual resilience as a solution to structural and
systemic challenges that hinder CHWs. In their efforts to promote community health,
policymakers must incorporate CHWs perspectives, lest they unintentionally further health
inequities by adopting policies (e.g., certification processes and requirements) that exclude
CHWs, creating further hoops to jump through for already overextended and underserved
essential workers. Additionally, policymakers should consider policies that may benefit other
healthcare workers but overlook lay CHWs. For example, despite healthcare worker burnout
44
being named a priority for the U.S. Surgeon General in a recent advisory calling for more fair
pay, equitable and empowering practices, and other necessary support (Office of the Surgeon
General, 2022), CHWs were named only three times, and emphasized as community
representatives and as collaborators in health initiatives rather than respected health workers in
need of support just as their clients are. CHWs are irreplaceable advocates for community wellbeing, and bolster the health of vulnerable communities; thus both research and policy should
reflect their impact and value in order to truly advance health equity.
45
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Appendix A: Savoring Task Protocol
*Bolded text is intervener script. Note that, while the below protocol is in English for ease
of review, the intervention was also (primarily) delivered in Spanish.
*Unbolded text is intervener instruction.
“Promotores/Community Services Providers (say whichever term applies to the person)
often tell us they don’t have much time to focus on the positive experiences they’ve had
helping the community because they are so busy doing their work and don’t have time
to stop and reflect. And yet, we know that promotores/Community Services Providers
are the “heart of the community,” lifting the community up and holding them
together. You deserve a time to focus on all of the good that you are doing in your
community and so the purpose of this program is to help you find time to focus on the
positive change you are having in your corner of the world.
For the next few minutes, I am going to help you come up with a memory of a time when
you felt extremely connected, close, helpful, or important in your community while you
were doing your job as a promotora/Community Service Provider. I am especially
interested in hearing about a time when you found joy in helping someone in your
community reach new heights, or a time when someone needed you and you were there
for them. It may be a time when you provided support for someone in your community
who really needed you. Or it could be a time when you saw how the work you were doing
lifted the whole community up. Feel free to choose something that you felt was a
milestone or something simple that happens on a daily basis.
What I’d like you to do is try to come up with some memories and then I’ll help you
decide which one to focus on for the next part of the study. Some people can think of just
one and some people can think of several. It doesn’t really matter how many you can
think of; we’re just going to be brainstorming. So can you tell me a time when you felt
this way with your community or with a person in your community?”
Ask the participant to tell you the memories that come to mind. After each one, ask the CSP how
connected they felt to the person and the community and how detailed the memory is. Complete
54
the Mental Reflection rating sheets as you discuss the memories with her. Keep in mind that we
are really looking for memories of a time when the CSP acted as a secure base/safe haven for the
community or for a member of the community (though you will not ask CSP specifically about
this). You will then ask the CSP to focus on the memory that describes a time when they felt the
most connected and can remember the most detail about the event. Remember, we are looking
for positive memories. If possible, we would like them to choose a memory that is devoid of
negative emotions. So a memory that contains both intensely positive and negative emotions will
not be as good as a memory that contains only a less intense positive emotion. If the participant
generates multiple memories of times when they felt extremely connected to the community with
extensive detail, then you pick the one that has the strongest secure base/safe haven content. If
the CSP generates multiple memories that are high on all of these qualities (positivity, detail,
secure base/safe haven content), ask the participant which one she would like to focus on for this
task.
When guiding the participant to the memory you’d like them to focus on, try to use a
transition phrase that fits well for the situation. Some examples are:
• It sounds like the first memory is really salient in your mind. Let’s focus on that one
for today…
• Since the second memory was more recent, we’ll go with that one today…
• It sounds like you have already spent some time processing this memory so let’s
go with the other one today…
If the participant does not generate any memories with explicit secure base/safe haven content
(e.g., CSP comes up with three memories of activities she at work), then your job is to ask some
additional questions to get the CSP into an attachment state of mind. Something like this:
It sounds like you really enjoyed being able to expose the person to something new or
exciting. During that experience, did you notice moments when the person relied on you,
55
or felt more comfortable because you were there? Were there things that he/she did that
he/she wouldn’t have been able to do without the confidence of knowing you were there?
After you get the participant to that place, you will want to remind them of this attachment
focus when directing them to focus on this memory:
Now, when focusing on this memory, I want you to really focus on the moments when
your being there helped your community or a particular community member, and how
you felt at those times. Tell the participant that you want them to focus on this memory
while she completes this next task.
“What’s going to happen now is that I’d like for you to sit comfortably and relax. I’m
going to have you really focus on this memory for the next 10 minutes. I’ll ask you to
focus on specific parts of the memory at different times and the feelings you had during
this special moment with “the community/this person in your community.” You can feel
free to relax and close your eyes if that will help you focus.
Now I’m going to ask you some questions and I’ll pause a bit in between so you have a
chance to reflect on your feelings. For each question, I will give a few examples of things
you may want to think about as you focus on this memory, but when you respond, don’t
feel the need to answer each and every question. As you reflect on your feelings during
that special moment with your community/this person in your community, please speak
those feelings out loud. And if you run out of things to say, don’t worry about it and just
keep thinking about the experience until I ask you another question. If you notice that
your mind wanders to unrelated or negative thoughts, just gently bring it back to the
positive aspects of this event. Does this sound okay? Do you have any questions?”
Record the stopwatch time before you begin reading the prompts. Read the prompts slowly to
the participants and give her plenty of time to reflect and respond.
1. I’d like you to relax and begin focusing on the time when with
56
the community/this person in your community. First, I want
you to notice and remember the details of the event. What was the weather like
that day? What time of day did the event occur? What did (other
person/people) look like or what were they wearing? Do you remember what
you were wearing? What kinds of sounds could you hear? What kinds of
things could you see?
2. Now I’d like you to notice how you felt at this time. What kinds of things were
you feeling in your body? Were you feeling happy and excited, or were you
deeply calm and relaxed? Think about where in your body you felt these
emotions and try to feel them now.
3. Now I’d like you to think about what you were thinking when
(memory). For example, were you thinking, “ (other
person/people) really needs me at this moment and I’m there for them.
I’m so proud to have this role in my community. I am taking such good care
of my community.” And what do you think about it now?
4. Now I’d like you to turn your focus to the future. Focus on how close you felt to
(other person/people) at that time. Focus on how close to felt to
the broader community at that time. How will the bond that you have with the
community now impact your ability to serve your community in the future?
How will it affect your connection to the community? How will this bond affect
the community overall? What positive things can you imagine happening as a
result of your bond to one another?
5. For the last part of this reflection, please let your mind wander in any way
you’d like related to this event. You may want to think about things I have
asked you to think about earlier or you may want to think about how this
memory is related to your other relationships and your life. It’s normal for
57
your mind to wander to other topics or feelings – if you notice that your mind
has wandered, just gently bring it back to the positive aspects of this event. Let
your mind wander in any way you’d like, but try to keep focused on the
positive, personal parts of this memory.
Once ten minutes is up or when reflection has ended, say to participant:
“Lastly, is there anything else you would like to say about this memory, or do you
have any take-aways from engaging in this reflection process? Thank you so much for
sharing this wonderful/important/meaningful memory with me. I look forward to
meeting with you next week.”
Abstract (if available)
Abstract
Background. Latine communities have long faced stark health inequities and systemic barriers to accessing healthcare services. Community health workers (CHWs) serve as a key link between patients and the often-daunting healthcare system, providing crucial health education and support. Despite this important yet demanding role, little is known about CHWs’ personal experiences of community health promotion and how they might draw upon their work for strength and endurance. The present study explored the potential for relational savoring, a procedure that elicits feelings of closeness and connection, to capture CHWs’ experiences of community health promotion and shed light on the relationship between these experiences and CHWs’ own well-being. Method. CHWs (n = 30) from California community health agencies completed audio-recorded tasks in which they recalled and mindfully savored service provision memories. Participants also completed questionnaires on burnout and psychopathology. Study participation was part of a larger IRB-approved study. Transcripts were examined via inductive thematic analysis. Exploratory bivariate correlations were conducted to examine associations between qualitative code frequency and measures of burnout and psychological distress. Results. Four themes were identified: Fulfilling Experiences, Sources of Resilience, Challenges of Community Health Work, and Support Net. Exploratory analyses revealed significant associations between qualitative codes related to interpersonal connectivity, intrinsic motivation, and exceeding work expectations, and quantitative self-reported psychopathology and burnout. Significance. The proposed study expands our understanding of key caregiving processes in key community health workers to improve individual and group-level mental health outcomes in Latine communities.
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Zhou, Elayne
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Core Title
Savoring the service: a mixed-methods study of Latine community health workers’ health promotion efforts
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Psychology
Degree Conferral Date
2024-12
Publication Date
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