Uncovering the Role of Community Health Worker/Lay Health Worker Programs in Addressing Health Equity for Immigrant and Refugee Women in Canada: An Instrumental and Embedded Qualitative Case Study Sara Torres Ospina Thesis submitted in partial fulfilment of the requirements for the PhD degree in Population Health Faculty of Graduate and Postdoctoral Studies University of Ottawa © Sara Torres Ospina, Ottawa, Canada, 2013 Uncovering the role of Community Health Worker/Lay Health Worker Programs in addressing health equity for immigrant and refugee women in Canada: An instrumental and embedded qualitative case study Abstract “Why do immigrants and refugees need community health workers/lay health workers (CHWs) if Canada already has a universal health care system?” Abundant evidence demonstrates that despite the universality of our health care system marginalized populations, including immigrants and refugees, experience barriers to accessing the health system. Evidence on the role of CHWs facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton, Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op, an independently-run multicultural health worker co-operative, which contracts with health and social services providers in Edmonton to offer linguistically- and culturally-appropriate services to marginalized immigrant and refugee women and their families. The two embedded mini-cases are two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under study is the Multicultural Health Brokers’ practice. I triangulate multiple methods (research strategies and data sources), including 46 days of participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers, ii mentors, women using the programs, health professionals and outsiders who knew of the work of the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy documents, yearly reports, training manuals, educational materials as well as quantitative analysis of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of both descriptive and analytical reflections taken throughout the onsite research. I also triangulate various theoretical frameworks to explore how historically specific social structures, economic relationships, and ideological assumptions serve to create and reinforce the conditions that give rise to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized populations’ access to health and social services. Findings reveal that Multicultural Health Brokers facilitate access to health and social services as well as foster community capacity building in order to address settlement, adaptation, and integration of immigrant and refugee women and their families into Canadian society. Findings also demonstrate that the Multicultural Health Broker model is an example of collaboration between community-based organizations and local systems in targeting health equity for marginalized populations; in particular, in perinatal health and violence against women. A major problem these workers face is they provide important services as part of Canada’s health human resources workforce, but their contributions are often not recognized as such. The triangulation of methods and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’ contribution to immigrant and refugee women and their families’ feminist urban citizenship. iii Acknowledgements In one of my colleagues’ PhD defense someone said “it takes a village” for a student to complete a PhD. This statement could not have been truer in my journey to finish this program. Words of thanks go to everyone who helped me in so many ways. The participants in my study: the Multicultural Health Brokers Co-op, the Multicultural Health Brokers, Alberta Health Services Edmonton Zone and its health professionals, who let me into their world, shared their stories, and trusted me to share their experiences with others in a scholarly way. I want to specially mention Yvonne Chiu, Executive Director of the MCHB Co-op, who taught me a lot during my study journey, and Lorraine Green of AHS, who made it possible for me to navigate the many research structures of the health system. Thank you. My thesis supervisor, Denise L. Spitzer, and thesis committee members – Carol Amaratunga, Caroline Andrew, and Ronald Labonté – have my enduring admiration and respect for their insightful comments and guidance throughout this process. Thank you. My friends who helped me in so many ways – with graphic design, Excel and editorial work – even when they were under pressure with their own jobs, and who also gave me moral support, socialized with me, and all too frequently had to understand my very limited time for non-academic activities (Madeleine Bachand, Shellie Bird, Ethel Broder, Jennifer Castro , Alma Estable, Nupur Gogia, Beth Greenhorn, Lois Marion, Lise Martin, Mechthild Meyer, Marika Morris, Janet Mrenica, Steffi Ortiz, Maguy Robert, John Young, Xavier Van de Maele, and Bessa Whitmore). Thank you. To my first official editor, Hilary Burke, for her patience and teachings: Thank you. Thanks also to my university colleagues who were there to share many narratives on my progress and roadblocks. The PhD program staff (particularly, Roseline Savage) who were always patient and had clear answers to my queries. Merci. My daughters, Tamara and Melisa Pubil-Torres, who were always there for me and kept encouraging iv me by saying, “Mom, it is time for you to finish”, and my relatives – my Mom, Alba Lilia Ospina, and my sisters, Ana, Angelica, Beatriz, Lilia, Lucrecia, Matilde, Oliva, and Rachel Torres, and all my other extended family – including my nieces and nephews, who are too many to name, but who gave moral and spiritual support, and also understood why I missed several family gatherings. Mil gracias. And, my long-time partner, Peter Broder, who listened, supported, and encouraged me in many ways, but without whom this journey would not have been possible. Thank you. I am proud to have you in my village and I will endeavor to support and encourage you in future in any way possible. This phase of my journey is ending, but many others are just beginning. Do count on me as well. I also want to mention three people although they are not physically part of my village; they are still part of this journey. First, Michèle Kerisit, who was a member of my thesis committee until her passing, and even when she was seriously ill asked me about how I was progressing in my program. Second, Ana Osorio, a long-time friend and colleague with whom I shared many international development experiences in El Salvador. Third, my brother, José Sibar Torres, who also did not live long enough to allow me to tell him that I am done, but with whom I am celebrating in spirit. The loss of these three people brings to mind a poem of a famous Chilean musician, Facundo Cabral, who wrote once in Spanish: “El que murió, simplemente Se nos adelantó, porque para allá vamos todos. Además, lo mejor de él, amor, sigue en tu Corazón”. [Free translation: He/she who died, just left ahead of us, because we are all going in that direction. What is important is that the best of he/she stays with us, love, continues to be in your heart]. v Dedication I dedicate this thesis to my mother who showed me the importance of perseverance, commitment and loyalty in every aspect of my life. Mother you are my source of strength, love and desire to achieve the unachievable. vi Table of Contents Abstract .......................................................................................................................... ii Acknowledgements ........................................................................................................ iv Table of Contents .......................................................................................................... vii List of Tables ............................................................................................................... xviii List of Figures ................................................................................................................ xix Definitions ..................................................................................................................... xx Chapter 1 ........................................................................................................................ 1 Introduction .................................................................................................................... 1 Statement of the problem .................................................................................................... 8 Chapter 2 ...................................................................................................................... 10 Theoretical framework .................................................................................................. 10 Theorizing the Community Health Worker Field in Canada ............................................... 10 Introduction ........................................................................................................................ 10 Situating myself ........................................................................................................ 10 Theorizing Health Brokers’ practice ................................................................................... 17 Multicultural health brokering theory .......................................................................... 17 A health promotion empowerment approach .............................................................. 19 Theorizing authoritative and experiential knowledge .................................................. 21 Theorizing agency and relational autonomy ................................................................. 24 Theorizing feminist urban citizenship ........................................................................... 30 Theorizing Feminist political economy .......................................................................... 34 vii The social location of health brokers within Canada’s health human resources workforce................................................................................................. 40 Gender and class ...................................................................................................... 41 Conclusion .......................................................................................................................... 43 Chapter 3 ...................................................................................................................... 45 Literature Review .......................................................................................................... 45 Who are Community Health Workers and why are they important? ................................ 45 Method ..................................................................................................................... 47 Results ...................................................................................................................... 49 Community Health Workers in Canada and in other countries .................................... 50 The micro view ......................................................................................................... 52 Effectiveness and improving health outcomes ........................................................ 52 Universality and workforce size ............................................................................... 53 CHW activism in the U.S. .......................................................................................... 53 Scope of practice ...................................................................................................... 54 Training ..................................................................................................................... 55 Supervision and technical support ........................................................................... 56 Service provision versus community development ................................................. 57 Cultural approach or concordance workers ............................................................. 58 A global view of CHWs as health human resources workforce ............................... 58 Typology of CHW models in Canada ........................................................................ 61 Characteristics of Canada’s CHW workforce ............................................................ 63 Background on Co-operatives ....................................................................................... 65 An overview .............................................................................................................. 65 viii The European experience ........................................................................................ 67 Principles of Health Co-operatives ........................................................................... 68 Successes in establishing worker Co-operatives ...................................................... 69 Internal factors ......................................................................................................... 69 External factors ........................................................................................................ 70 Challenges in sustaining worker Co-operatives ....................................................... 70 Ethnocultural and immigrant Co-operatives ............................................................ 71 Chapter 4 ...................................................................................................................... 73 Research Design ............................................................................................................ 73 About this narrative ............................................................................................................ 73 Research questions ....................................................................................................... 75 Case study theoretical propositions ......................................................................... 76 Selection of the Case ..................................................................................................... 80 Limitations of case study research ........................................................................... 82 Research methodology .................................................................................................. 82 Transformatory-Emancipatory ................................................................................. 82 Research strategies ....................................................................................................... 84 Participant observation ............................................................................................ 84 Direct observation .................................................................................................... 85 Face-to-face in-depth interviews ............................................................................. 86 Sampling ................................................................................................................... 86 Obtaining consent .................................................................................................... 87 Transcription of interviews and note taking ............................................................ 89 Pilot testing and interviewing .................................................................................. 90 ix Document review ..................................................................................................... 90 Archival data............................................................................................................. 91 Health Brokers caseload database ........................................................................... 91 The choice of pseudonyms ....................................................................................... 93 Coding and analysis .................................................................................................. 93 Theoretical triangulation .......................................................................................... 95 Field notes ................................................................................................................ 95 Ensuring scientific quality/Trustworthiness ............................................................. 96 Member checking ..................................................................................................... 96 Methodological strengths and drawbacks ............................................................. 100 Critical reflexivity .................................................................................................... 100 Chapter 5 .................................................................................................................... 102 The Multicultural Health Brokers Co-operative: The Case ............................................. 102 Targeting health equity by integrating theory, practice, and democratic principles .......................................................................................................................... 102 A holistic approach ........................................................................................................... 102 How this Chapter is organized ............................................................................... 104 Gender composition of Health Co-op members and workers ............................... 105 a) Developing a market niche ................................................................................ 105 Health Co-op’s Programs summary ....................................................................... 107 Participating in research with academic institutions ............................................. 113 Creating social enterprises (small business) .......................................................... 114 Creating a sister organization with charitable status ............................................. 115 b) Enhancing the internal capacity of the organization ......................................... 116 x