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ABSTRACT Community health workers (CHWs) are front-line public health personnel who share common attributes with or have a nuanced understanding of the communities they serve. Their membership in marginalized communities gives them expertise in delivering contextualized interventions that mitigate their clients' social risk factors, but it also places them at greater risk for exposure to various harms. We employed the photovoice method to illuminate how the lived experiences of CHWs working, residing, or both in Baltimore City, Maryland, dovetail with facets of their jobs. In partnership with our sixteen predominantly racial and ethnic minoritized study participants, we surfaced the ways in which CHWs negotiated and subsequently leveraged experiences with social risk factors rooted in structural racism to shape their approach to intervention delivery for structurally vulnerable communities. We also uncovered several occupational hazards that participants faced as a function of their identities. Our findings underscore the need to embed antiracist principles in the fabric of policies and practices that directly affect the CHW workforce.
Social determinants of health (SDOH) comprise the social, physical, and economic circumstances that affect health.1,2 They exert their influence through interlocking causal pathways that link structural, upstream determinants, including sociopolitical, economic, and cultural factors such as racism, classism, and other forms of oppression, '5 to downstream determinants, such as medical care, health education, and behavioral risk factors.5 Their convergence profoundly shapes the systems and policies that influence neighborhood conditions, education, income, and psychosocial well-being. As such, adverse exposures to SDOH experienced on the individual level-or social risk factors-are excessive in systematically marginalized communities. These risk factors generate pressing health-related social needs.6 The confluence of these factors is responsible for producing and reinforcing health disparities.4
One proven strategy in disrupting the underlying mechanisms connecting health disparities with SDOH, social risk factors, and social needs is the implementation of community health worker (CHW)-led interventions. CHWs are front-line public health workers who are trusted members of or possess a deep understanding of (or both) the communities that they support.7 They have long been recognized as critical to linking structurally marginalized communities to health and social service resources that alleviate the impact of social risk factors and attendant social needs.s 10 Their personal characteristics, intrapersonal qualities, and interpersonal skills uniquely position them at the...