Fourteen individuals participated in the study (Table 1). Their years of experience in the field ranged from 0.5 to 22 years. Some participants’ current role titles included “community health workers” and “COVID-19 response workers,” with the latter group responsible for providing resources and COVID-19 education during the pandemic. Certain participants had advanced to the roles of “CHW supervisor” and “CHW coordinator”, overseeing CHWs and programs. One participant transitioned to the role of “communicable disease investigator,” surveying infectious diseases within local communities. The majority were affiliated with health systems (n=11, 78.5%) and served Chicago’s West side (n=8, 57.1%) and South side (n=8, 57.1%), with some participants working in more than one region of Chicago.

Table 1 Participant characteristics of experienced community health workers in Chicago, Illinois, US 2022 (n=14)Domain 1: Current work of CHWs

Five themes emerged from participants about the current responsibilities of CHWs: providing services to clients, building alliances with clients to improve health outcomes, establishing and maintaining collaborations, collecting data to support work, and navigating challenges in their work (Table 2).

Table 2 Themes, subthemes, and illustrative quotes related to current work of community health workers (CHWs), as informed by interviews with experienced community health workers in Chicago, Illinois (2022)Theme 1: Providing services

Participants emphasized their primary role is to provide services to clients seeking care for their needs. Examples of services included navigation of the health care system and linkage to health and social resources. Participants reported additional services for clients included educating about health topics, delivering materials (e.g., green cleaning kits, medications), and troubleshooting issues negatively affecting care – all of which are addressing “what the patient [client] needs.”

Participants also shared their contributions to the development and implementation of CHW programs, including supporting design of programs and materials. CHWs applied their unique expertise to developing projects. For example, one participant shared, “Sometimes, especially when it’s a new program, it’s rare [to have] things come in translated; or when you’re getting trained, you don’t get trained in Spanish. You have to do your own translation.” Participants described additional responsibilities including conducting recruitment, data collection, and trainings. One participant described that they ensured continuing education was available, “I’m trying to get courses or presentations to be available to CHWs as we move into different roles or things they want to get a refresher on.”

In specific settings, participants described CHWs providing more tailored services. They discussed conducting health outreach and education at community events, such as health fairs. Although the COVID-19 pandemic paused direct outreach, some participants still conducted community outreach including canvassing schools to provide COVID-19 information: “if they wanted some information on the vaccination for their kids, for their parents, you let them [schools] know what you’re doing.” In clinical settings, CHWs can uniquely connect with clients to further learn about their health status and factors influencing their health to inform clinicians as one participant explained, “a lot of times our clients [are] not comfortable speaking and being open with their physicians… It’s our job to listen to them and then relay the message back to the doctor’s office.”

Theme 2: Building alliances with clients to improve health outcomes

Participants described that, for CHWs to effectively provide services, a significant part of their work is establishing trust with clients. They emphasized the importance of CHWs utilizing their communication and interpersonal skills by being attentive to clients’ needs, connecting with clients through shared experiences, being transparent with clients, and assuring clients of their support. One participant shared how they first interact with clients, “I introduced them myself or even let them ask me question… Things like that have also been very helpful in building that rapport with the participants.”

Additionally, the various ways that CHWs interact with clients can help establish alliances. Participants expressed that in-person contacts through door-to-door canvassing and home visits effectively built trust with clients. While the COVID-19 pandemic resulted in limited in-person interactions with clients, one participant emphasized the importance of continuing meaningful engagement with clients in virtual environments, “Having that time to talk with them and to ask those opening questions to see what’s the root cause of what’s going on and then try to address that so it can change some of the other outcomes.”

Theme 3: Establishing and maintaining collaborations

Participants also described how their current work leverages their various relationships with partners: collaborators within health systems, CHW teams, community organizations, and community members.

Participants affiliated with a health system described working across departments and collaborating with various personnel to support patients. They indicated the integration of CHWs into health teams has become an easier process with health systems becoming more familiar with CHWs as one participant shared.“When I first started as a CHW, a lot of people weren’t aware of us. Right now, we are popular.” Further, some participants explained that they worked directly with clinicians in the health system to coordinate care for clients. One participant emphasized the importance of consistent communication in this partnership, “Sometimes it can happen that they [clinic staff] make the same appointment, or they forget to make the appointment so it’s [important] to keep them updated about what resources you [CHWs] are providing.” CHWs also relied on collaborations within the health system to acquire knowledge and resources. One participant shared about their partnership with social workers, “[Social workers] know a lot. If they don’t know or if I don’t know, they’re finding the best way to figure it out.”

Beyond the health system, participants shared that it was essential to collaborate within their CHW teams. Participants expressed these partnerships have helped them be effective and stay motivated in their roles, especially during a public health crisis. Some participants shared that, even with limited in-person interactions, they made time to meet with their coworkers to share successes and challenges as one participant explained, “If it is something I don’t feel that I’m dealing with correctly, our CHWs are so open to assist you [me].” Additionally, through these partnerships, CHWs were able to share their expertise to support each other’s clients. One participant described, “We work on different projects… ‘I have an asthma patient. Could you talk to them? Could you do education?’ I’ll just call them and then they’ll come do the education.”

In addition to working with health systems and CHWs teams, CHWs discussed their collaborations with community organizations, community members, and other partners (e.g., CHW associations and groups) to gather and expand resources. CHWs worked to develop partnerships with local organizations and external networks to link clients to resources (e.g., food pantries, housing assistance) as well as to provide health education to community members. One participant shared the benefits of having such local partnerships to minimize gaps in resources, “If there’s one [service] that we don’t offer, then [we are] reaching out to organizations that offer [the service].” Participants described that these partnerships can be bidirectional with CHW providing trainings to these organizations. Also, participants stated CHWs worked closely with community members to tailor their services to community needs. For instance, CHW programs have organized community advisory boards to obtain suggestions to enhance the programs. One participant shared how they leverage their community advisory board to enhance a CHW program, “We do have a community advisory board. Whenever we want to do changes to our programs, we try to connect with them to see what they say and one of those is an example of our name. We’re trying to be more inclusive and more gender neutral…so we went to our advisory board.” Additionally, participants have worked with CHW networks to build knowledge and expertise as one participant shared, “Joining the national CHW organization – that’s a must because you’re getting information.”

Theme 4: Collecting data to support work

Some participants described significant involvement in data collection as a part of their roles. They stated that CHWs collect health and social-related data to identify factors influencing health outcomes as well as to monitor client’s progress in working with a CHW. Additionally, participants shared the importance of data collection for CHWs to track their own work progress. This data may be related to the reach and impact of their work, including the number of client interactions each day and number of clients who accepted or rejected services, resources, or referrals. Participants also talked about the importance of tracking outcomes of resources provided to clients to screen for the quality of services provided. One participant described the information they provide, “We enter the resources they need and if we provide it… and I enter notes because sometimes you have bad experiences.”

Participants indicated the data collected by CHWs are utilized for evaluation, maintenance, expansion, and dissemination of programs. Data on the outcomes of CHW services can highlight the successes of CHW programs as well as areas for improvement. For example, one participant shared how the data collected led to not only refining the program but also expanding it, “I was in a diabetes program. Before I started, it was called [program 1]. Once they collected that information, they saw some fine-tuning they needed to do and so they did it. Then, they created a second one, which was called [program 2]. That’s when they hired new CHWs. They brought in more because they realized they needed more CHWs to roll out this program.” Additionally, this data can bring to light the needs of vulnerable communities and impacts of CHWs through dissemination: “We use [data] to improve our programs. Use it to help tell the story of these community concerns we were addressing or identified through this programming. Data is our support and validation.”

Theme 5: Navigating challenges in role

Participants highlighted various challenges encountered in their community health work. One challenge was related to the different relationships within their roles. CHWs shared difficulties in their client relationships. Some participants discussed working on overwhelming client cases and coping by learning to create healthy boundaries and rely on other CHWs. CHWs also spoke about barriers in interacting with clients, especially virtually, which can limit communication. Participants shared that some clients may be heavily reliant on CHWs, while some may distrust them: “In the past, it was a struggle to get that trust from the community. The health care system has been very harsh towards Black and Brown individuals.” Beyond client relationships, some participants described challenges with integrating into clinical teams. Some experienced being unwelcomed by clinicians and other staff due to limited understanding about CHW role. One participant cited the insufficient recognition given to the work of CHWs, “The world doesn’t see a CHW like they would a CNA [certified nursing assistant] or another kind of assistant... it’s been verified and documented that having a CHW attached to a person within their health challenges makes a difference.”

Another challenge described by participants was related to gaps in resources for clients and materials needed to complete their work. Participants highlighted the limited funding to support clients and CHW programs. One participant described the struggles of overcoming financial barriers for clients to receive health care, “With COVID-19, a lot of people lost their employment… If there’s no resources, then it’s hard for people to commit to having a [medical] procedure.” Additionally, there are limited funds to provide as incentives to foster success in CHW programs.

Additional challenges raised by participants included fluctuations in work. They indicated the pandemic led to drastic changes with the transition to remote work, which affected how CHWs interacted with clients. One participant shared, “Now, it’s more difficult to get them [clients] virtually and actually show you [their] home... You would think it’s easier virtually because you’re not going in, but they don’t want to do it.” With remote work also comes the challenge of maintaining a work-life balance that participants reported, as one shared, “Some patients really do need support and they want to stay with you on the phone for hours and we can’t do that.” Lastly, participants discussed how the nature of home visits and community outreach posed a challenge due to increases in crime in the communities served: “Most of the neighborhoods that we work in are high crime areas… We could make our appointments for early in the morning and it’s usually safe in the morning, but now it’s just as bad early in the morning as it is in late evening.”

Domain 2: Strategies for CHWs to be successful in their roles

Five themes emerged from participants about strategies for CHWs to be successful in their roles: background, champions to support work, materials to perform work, preparation for role, and acquired characteristics (Table 3). These strategies aligned with a logic model, including inputs, activities, and outputs with the outcome of an effective CHW (Fig. 1).

Table 3 Themes, subthemes, and illustrative quotes about strategies for community health workers (CHWs) to succeed in role, as informed by interviews with experienced community health workers in Chicago, Illinois (2022)Fig. 1

Logic model describing strategies for community health workers to succeed in role, as informed by interviews with experienced community health workers in Chicago, Illinois (2022)

Theme 1: Background of CHWs

Participants highlighted innate attributes to consider when hiring CHWs. One characteristic considered important was being a member of the community served. Participants shared this quality was valuable for navigating local resources and building trust with clients. Participants emphasized the importance of having shared backgrounds (e.g., demographics, experiences) and language with clients to build trusting relationships. One participant shared that having the same adversities as clients prepared them to join the workforce, “I was the mother waiting in a room to get the service, and nobody gave the service because [there was] nobody who speaks Spanish... I'm not the first, but I'm not the last one. That gave me that responsibility.” Along with shared backgrounds as clients, participants reported certain past experiences that transferred to their roles, including education in psychology or sociology as well as previous roles in health or helping others.

Theme 2: Champions to support the work of CHWs

Participants listed key players who have supported their role as CHWs. An essential entity identified by participants as a champion was their own internal organization. They expressed appreciation that their organization’s culture encourages collaborations and nurtures professional growth by providing education and materials. One participant shared about their organization, “I think one of the reasons that I really like to do what I do is because I feel supported and because, like [organization’s] philosophy, if we’re okay emotionally, we can better perform our job.”

Internal to their organizations, participants reported their CHW teams were champions for their work. Their team members were especially helpful by providing guidance and emotional support, particularly when starting in their roles. One participant described their team member’s lasting impact when beginning their role, “Something came up...I’m like, ‘I can’t do this. I’ve got to find something else to do.’ My [team member] was like, ‘Okay, see you tomorrow’… When people new come to me, I’m like, ‘Okay, let’s take a deep breath. Go home and do some self-care. I’ll see you tomorrow. Tomorrow, let’s talk about what happened yesterday.’” In addition to serving as champions at the start, participants emphasized that team members helped enhance their performance by sharing expertise and resources as well as creating space to debrief on difficult cases. Lastly, participants stated the leaders within their teams are champions for their work, providing support and resources for CHWs to be effective in their role. One participant shared the importance of having a leader who respects them, “Having that type of support with your supervisor does make that type of work a lot easier...it makes [me] happy to be working in that field.”

Outside of their organizations, some participants recognized external organizations as champions for their work. Participants shared that they relied on other CHW-focused organizations for topic expertise and client referrals. Participants who have been integrated in clinical settings emphasized the importance of having a clinician who trusts the CHW and serves as a champion. One participant shared their experience, “I have this one champion...she is a doctor still. She is the one that was, ‘go ahead and talk [to] them,’ ‘go ahead and do this,’ ‘go ahead and tell them.’”

Theme 3: Materials to perform work of CHW

Participants highlighted the various materials needed in their line of work. A key material was readily available resources with information and referrals for clients, such as community referral programs like “Purple Binder” and “NowPow”. One participant described how they use such resources with clients, “I have physical resources. I can get copies and highlight numbers they’ve got to call, addresses, appointments.” Participants also shared that CHWs need materials for client care, including medications, medical supplies, and cleaning products to support chronic condition management at home. During the COVID-19 pandemic, they also provided personal protective equipment and at-home tests. Further, participants discussed that communication tools were important for working with clients and their teams, including phones, social media, and translated materials for non-English speaking clients. For their data collection responsibilities, CHWs typically used laptops or tablets to record their work and as appropriate database software. Participants also suggested CHWs should have paper versions of documents in times without Wi-Fi access. To support client education, participants recommend CHWs should have presentations as well as visual tools like anatomical models and practical materials (e.g., diabetes and asthma devices) to demonstrate aspects of disease management. As for continued education, participants largely relied on online tools like Coursera and YouTube.

Theme 4: Preparation for CHW role

Participants reported training and continuing education were essential to be prepared for the CHW field. Specifically, participants highlighted the various lessons from CHW core skills training, which focuses on relevant competencies and skills that were applicable when working closely with diverse clients. One participant shared they felt prepared for the CHW role after completing such training, “I had to understand culture humility...how to communicate with physicians...how to document... Once the expectation had been set and the knowledge has been layered on that, then it gets you ready to do the work in hand.” In addition, participants reported trainings on various health topics prepared them to support condition-specific programs. Some participants were cross-trained on multiple health topics, including chronic health conditions (e.g., asthma, diabetes, breast cancer), mental health, and COVID-19. These trainings ensured that CHWs attained knowledge on health topics to share with clients, as described by one participant, “We can all jump in different interventions and educate a person. If I’m seeing somebody for breast health and I know that person has asthma, I can interject some of my asthma knowledge.” Along with CHW core skills and health topic trainings, participants emphasized the importance of having practical experience through role-playing, shadowing experienced CHWs, and learning on the job. One participant shared, “If you don’t have experience from doing home visits with the educators…having face-to-face contact with people… you're never going to have that connection with people [clients].” Also, participants emphasized the importance of continuing education to provide quality services to clients. Participants described they have requested subject-specific training on health topics and skills from their internal organization as well as conducted their own research or completed online trainings to ensure up-to-date knowledge.

Along with trainings, participants shared it is vital for individuals to complete other preparation for their role, including developing familiarity with the people and needs of communities they are serving. In addition, some participants emphasized the importance of knowing the community for their safety, as one participant shared, “You can’t help anyone if you’re not around to help anyone.” Finally, some participants highlighted additional preparations related to programming, such as reviewing materials and understanding responsibilities.

Theme 5: Characteristics of CHW

Participants listed qualities and skills that individuals should have to work in the CHW field, some of which are gained or refined through external experiences and preparation for their CHW role. They commented that key qualities of a CHW include being respectful, flexible, and compassionate. Participants emphasized the importance of being comfortable working with others when taking on the role of CHW, as one participant stated, “People can sense when you’re genuine and when you actually want to help them.” In addition, participants commented that it is important to be empathetic, especially when working with various clients with different backgrounds. One participant stated, “You’ve got to be open to work with all kinds--homeless, intoxicated people, people in a bad mood. You need to be empathetic... It is still your duty to help them.”

Regarding skills necessary to be an effective CHW, participants highlighted resourcefulness, interpersonal skills, problem solving, and time management. They emphasized the importance of having strong communication skills to work with various parties – clients and individuals within both internal and external organizations. One individual stressed the importance of tailoring communication style for clients with various backgrounds, “You have to be able to speak to anyone on any level - street level, education level...You’ve got to be able to deal with any type of person.” In addition, participants commented that it is important for CHWs to be mindful of their limitations and create healthy boundaries in their role, “At the beginning, I wanted to do it all. I thought, ‘I could do this, I could do that.’ And then, it was causing burnout…saying no as well was something that just made me more efficient [and] successful.”