May 23 2016 Visit us at wwwdectrorgcommunity wwwdectrorgforum Work supported by an Institutional Development Award IDeA from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54GM104941 PI BinderMacleod ID: 683898
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Slide1
Session
A – Platform PresentationsMay 23, 2016
Visit us at:
www.de-ctr.org/community www.de-ctr.org/forum
Work supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Binder-Macleod).Slide2
A Crowdsourced Social Media Portal for Parents of Young Children with Type 1 Diabetes:
Initial Content Development
Jessica Pierce, Ph.D.
Assistant Research Scientist, Center for Healthcare Delivery ScienceTim Wysocki, Ph.D.Co-Director, Center for Healthcare Delivery ScienceKaren Banta
Community PresenterSlide3
Learning objectivesSlide4
Type 1 diabetes in infants, toddlers, & preschoolersSlide5
Basic structure of the projectSlide6
Methods
Health Care Provider Crowd
Family Advisory Committee Slide7
YammerSlide8
ResultsResponse RateMean = 115All questions = 88At least 1 question = 152No questions = 18
Average length of replies = 105.6 wordsThemes and examples integrated into a Social-Ecological Framework & TaxonomySlide9
Social-Ecological Framework
COMMUNITY
CHILD
WITH
T1D
PARENTS
SOCIAL CIRCLE
FAMILY UNIT
Marriage
Relatives
Parents as
Individuals
Career
Siblings
Family as a Whole
Friends
Peers and their Parents
Child
care
Pre-
school
T1D
Friends
Health
care providers
Health care organizations
T1D Education
&
Advocacy
Insurance, Payers, & Pharmacies
Laws & RegulationsSlide10
Child with T1D TaxonomyCHILD WITH T1D
CATEGORY: CHILD WITH T1D MAY EXPERIENCE MANY
CHALLENGES
THEMESEXAMPLESInability to report hypoglycemia
Young kids aren’t able to accurately report when their BG level is low.Is this related to diabetes symptoms or is my child misbehaving?It can be difficult to know whether a given child behavior is or is not a direct symptom of T1D.Food issues: picky eating, unpredictable appetite, resistance to limit setting
Children with T1D, like those without T1D in this age group, tend to have very unpredictable and variable eating habits and preferences, making it difficult to balance their food intake against their insulin needs. They resent being unable to eat like other children.
Loss of carefree spirit
Children with T1D may become more serious and controlled than their peers, less able to “just be a kid”.
Requires special treatment
Normal play and social interaction with other kids is often interrupted for T1D care needs. Kids with T1D can’t eat as spontaneously as other kids can.
Variation in activity level
Children in this age group are highly varied in their activity levels, making it very difficult to juggle
carb
counts and insulin dosing to stabilize BG
Developmental changes
Growth spurts occur frequently in this age range. Basal and bolus doses work, and then growth spurt occurs which requires adjustments.
Coping with shots/sticks
Many/most children require an adjustment period to cope with shots,
fingersticks
, infusion set/pod changes, and/or CGM sensor changes.
Sick day management
Keeping T1D in control during sick days is a real challenge in this age group.
Limits on normal activities
T1D care during preschool, sports, play dates, etc. often requires limiting what the child with T1D is allowed to do, how/when it can be done, etc.
Limited T1D understanding due to developmental maturity
Young kids have a very limited ability to understand why they must cooperate with T1D care. They do not know about or think about short term and long term consequences.
Adjustment difficulties
Some very young children with T1D may be angry, aggressive, sad or frustrated toward their parents when it is time for painful procedures or the parent sets limits that the child doesn’t like.
Separation anxiety
Some children with T1D may have quite a bit of anxiety about separating from their parents for any significant period of time. May cling to parents in social or unfamiliar surroundings.
BG affects on thinking and learning
Parents are taught to avoid extremes of BG to prevent thinking and learning problems from developing, but it is very difficult to do this in the real world.
Stigma; segregation from peers
Kids with T1D are seen as different by other kids and their parents. Some kids may fear “catching” T1D themselves.
Implications of Celiac Disease
Children with T1D and celiac disease have even more special dietary needs since they must avoid foods containing gluten, which are everywhere.
Bedwetting
Bedwetting due to high BG during sleep may make some kids with T1D avoid sleepovers, etc.Slide11
CATEGORY: GIVEN THESE CHALLENGES, THESE ARE SOME POSSIBLE POSITIVE EFFECTS
OF HAVING TO DEAL WITH T1D***Note*** Many of you expressed that there are no benefits of T1D and we understand that all parents would trade any benefits/positive effects of T1D for cure. Here are some things that many parents find to be the “brighter side of T1D” or the “silver lining.”
THEMES
EXAMPLESEmpathy toward othersMany children with T1D tend to be more capable than other children of empathy for others with special needs. They learn to understand differences in people and embrace their own differences.
Daily focus on healthKids with T1D grow up knowing that it is natural to attend specifically to their health every day. Learn to make healthier choices and have heightened self care. Child doesn't know anything different
Children diagnosed with T1D at a very young age grow up accepting T1D care as normal. They don’t remember living any other way. On one hand this is sad, on the other it may help them accept T1D more easily.
Better math and nutrition knowledge
Living with T1D provides daily chances for parents to teach basic counting and arithmetic skills to their children with T1D.
Resilience
Child has become resilient, strong, confident, and brave. Less fearful of needles and other medical procedures.
Enhanced self-control
Ability to delay gratification compared to peers
Social maturity and responsibility
Child is more outgoing, child learns to speak up for him or herself, and more independent compared to peers. Children with T1D tend to mature more quickly and to become more serious and responsible compared with non-T1D peers.
Sweets are more special
Child with T1D really enjoy sweets/candy because it is not a routine part of diet.
Positive attention from others
Receive positive attention for bravery.
Child with T1D TaxonomySlide12
Future DirectionsSlide13
Jessica.Pierce@nemours.org
Questions?Slide14
ReferencesCameron, F. J. (2015). The impact of diabetes on brain function in childhood and adolescence. Pediatric Clinics of North America, Aug., 62 (4), 911-927.
Cole, P. M., Dennis, T. A., Smith‐Simon, K.E., & Cohen, L. H. (2009). Preschoolers' Emotion Regulation Strategy Understanding: Relations with Emotion Socialization and Child Self‐regulation. Social Development, 18, 324-52.Cathey, M., & Gaylord, N. (2004).Picky eating: a toddler's approach to mealtime. Pediatric Nursing, 30, 101.Dabelea, D., Bell, R. A., D'Agostino Jr., R.B ., Imperatore
, G., Johansen, J. M., Linder, B., et al. (2007). Incidence of diabetes in youth in the United States. JAMA: the Journal of the American Medical Association, 297, 2716-24.Herbert, L. J., Monaghan, M., Cogen, F., & Streisand R. (2014). The impact of parents' sleep quality and hypoglycemia worry on diabetes self-efficacy. Behavioral Sleep Medicine, 1, 1-16.Hilliard, M. E., Monaghan, M.,
Cogen, F. R., & Streisand, R. (2011). Parent stress and child behaviour among young children with type 1 diabetes. Child Care, Health and Development, 37, 224-232.Monaghan, M., Herbert, L. J., Cogen, F. R., & Streisand, R. (2012). Sleep behaviors and parent functioning in young children with type 1 diabetes. Children’s Health Care, 41, 246-259.Monaghan, M., Herbert, L. J., Wang, J., Holmes, C., Cogen, F. R., & Streisand, R. (2015). Mealtime behavior and diabetes-specific parent functioning in young children with type 1 diabetes. Health Psychology, 34(8), 794-801.Monaghan, M. C., Hilliard, M. E., Cogen, F.R., & Streisand, R. (2009), Nighttime caregiving behaviors among parents of young children with Type 1 diabetes: associations with illness characteristics and parent functioning. Families, Systems and Health, 27, 28-38.Patterson, C. C., Dahlquist, G. G., Gyürüs, E., Green, A., & Soltész, G. (2009). Incidence trends for childhood type 1 diabetes in Europe during 1989–2003 and predicted new cases 2005–20: A multicentre prospective registration study. Lancet, 373, 2027-2033.
Patton, S. R., Dolan, L. M., & Powers, S. W. (2006) Parent report of mealtime behaviors in young children with type 1 diabetes mellitus: Implications for netter assessment of dietary adherence problems in the clinic. Journal of Developmental and Behavioral Pediatrics, 27, 202-208.Patton, S. R., Dolan, L. M., Smith, L. B., Thomas, I. H., & Powers, S. W. (2011). Pediatric parenting stress and its relation to depressive symptoms and fear of hypoglycemia in parents of young children with type 1 diabetes mellitus. Journal of Clinical Psychology in Medical Settings, 18, 345-352.Perfect, M. M., Patel, P. G., Scott, R. E., Wheeler, M. D., Patel, C., Griffin, K., et al. (2012). Sleep, glucose, and daytime functioning in youth with type 1 diabetes. Sleep, 35, 81-88.Powers, S. W., Byars, K.C., Mitchell, M. J., Patton, S.R., Standiford, D. A., & Dolan, L. M. (2002). Parent report of mealtime behavior and parenting stress in young children with type 1 diabetes and in healthy control subjects. Diabetes Care, 25, 313-318.Smaldone, A., & Ritholz, M. D. (2011). Perceptions of parenting children with type 1 diabetes diagnosed in early childhood. Journal of Pediatric Health Care, 25, 87-95.Stallwood, L. (2005). Influence of caregiver stress and coping on glycemic control of young children with diabetes. Journal of Pediatric Health Care, 19, 293-300.Streisand, R., Mackey, E. R., &
Herge
, W. (2010). Associations of parent coping, stress, and well-being in mothers of children with diabetes: examination of data from a national sample.
Maternal and Child Health Journal, 14,
612-617.
Streisand, R., & Monaghan, M. (2014). Young children with type 1 diabetes: challenges, research, and future directions.
Current Diabetes Reports, 14
, 520.
Sullivan‐
Bolyai
, S.,
Deatrick
, J.,
Gruppuso
, P.,
Tamborlane
, W., & Grey M. (2002). Mothers' experiences raising young children with type 1 diabetes.
Journal of Specialized Pediatric Nursing, 7
, 93-103.
Sullivan-
Bolyai
, S.,
Deatrick
, J.,
Gruppuso
, P.,
Tamborlane
, W., & Grey, M. (2003). Constant vigilance: mothers' work parenting young children with type 1 diabetes.
Journal of Pediatric Nursing, 18
, 21-9.
Sullivan-
Bolyai
, S. Rosenberg, R., & Bayard, M. (2006). Fathers' reflections on parenting young children with type 1 diabetes.
The American Journal of Maternal/Child Nursing, 31
(1), 24-31. Vehik, K., Hamman, R. F., Lezotte, D., Norris, J. M., Klingensmith, G., Bloch, C…Dablea, D. (2007). Increasing incidence of type 1 diabetes in 0- to 17-year-old Colorado youth. Diabetes Care, 30, 503-509Wysocki, .T, Huxtable, K., Linscheid, T.R., & Wayne, W. (1989). Adjustment to diabetes mellitus in preschoolers and their mothers. Diabetes Care, 12, 524-529.Slide15
Judith W. Herrman, PhD, RN, ANEF, FAAN Christopher Moore, BA, LSSGB
Brian Rahmer, Ph.D. Mellissa Gordon, Ph.D.Barbara Habermann, PhD, RN, FAAN
Video Journaling as a Qualitative Research MethodologySlide16
PurposeAs part of a larger, mixed methods study this qualitative component evaluates the Wise Guys
program using a unique video journaling technique to capture participants’ perspectives on the value of this male-oriented teen pregnancy prevention and health promotion program.Work supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Binder-Macleod). Slide17
Why new methods with teens?Issues with….
AuthenticityModes of expressionValidity and ReliabilityDevelopmental Appropriateness
EngagementTechnologically Driven YouthSlide18
Our Previous Evaluation of the Wise Guys Program
Study 1N=70Assessed Attitudes—Thoughts on Teen Parenting SurveyPre/Post test designSome positive changes in attitudes(Herrman, Moore, & Sims, 2013)Study 2
N=159, pre/post test designAssessed Attitudes—Thoughts on Teen Parenting Survey
Assessed additional attitudes toward sex, relationships, and communication with parentsAssessed Knowledge—general and STIsAssessed BehaviorsFound positive changes in behaviors and communication with parents(Herrman, Moore, & Rahmer, 2016)Slide19
Study IssuesIssues-surveying
teensNeutral answersLeave blanksLack of validityFidelity to program
Large number of unusable dataLack of consentsNo pre or post test
Educator errorNon-completion of programAnecdotal successes not captured in evaluationSlide20
Inception of the Video Journaling Project
Little Research on videosJewitt, C. (2012). An introduction to using video for research. London, UK: National Centre for Research Methods. Mixed-methods
Creswell, J.W., Klassen, A.C., Clark, V.L.P., & Smith, K.G. (2010). Best practices for mixed methods research in the health sciences. Washington, DC: Office of Behavioral and Social Sciences Research.
Morgan, D.L. (2014). Integrating qualitative and quantitative methods: A pragmatic approach. Thousand Oaks, CA: Sage. Slide21
Video Journaling Project MethodsTwenty young men who completed the
Wise Guys program- assent and permissionTraining on the VJP and given an IPod Touch with video capabilityThe participants were charged with taking videos of their daily life while considering how Wise Guys and the lessons learned impacted their daily lives through the lenses of directive questions. This self-reflective exercise was designed to address:
Personal goals and objectivesRecent accomplishments
Obstacles Social support and environmental factorsSlide22
Video Journaling Project
Protocol
Use of the IPod-Touch video capacity only for this project
Informed consent, confidentiality, and respect of privacy (participants cautioned to take pictures only of self)Aspects of behavior and safe/respectful use of video capacity, reinforced several times.Participants were encouraged to consider their personal values and potential consequences of inappropriate use, in accordance with the principles of Wise Guys.Slide23
Video Journaling
Check insEvery 1-3 days over three weeks Text messages by Research AssistantQuestions to guide their videos
Encouragement to be creative Reminders to videoSlide24
AnalysisVideos were downloaded to a passcode protected drop box.
Videos were merged such that each participant had one video. Participants were able to keep the IPods.Videos were transcribed and film clips and transcriptions were uploaded into
NVivo software, a qualitative data management system. This allowed for side-by-side perspectives to guide the content analysis and assessment for emergent themes. Slide25
Video Journaling Project-Results
Communication and Relationship Skills “Wise Guys showed me to communicate more to my partner…show respect and talk to her about stuff.”Thoughts on masculinity
“it teaches young men how to be a man and the steps and the process of being one.” Thoughts on Respect for Women
“A guy should respect women…shouldn’t be hittin’ on a girl…I don’t agree you should pay all the time…half and half…you’d be flat out broke!”Slide26
Video Journal Project Results (cont.)
Consequences of Unprotected Sex “You could really mess up women….that’s why is it’s important to respect
them…be safe…use condoms…make sure they say yes.”Consequences of Teen Parenting
“it taught me to avoid having a baby as a teen—it could mess with my goals.”Engaging in Safer Sexual Practices “if we want to have sex, we would like to be prepared, how to put on a condom, check the expiration date, put it on right.”Goal-setting/Impact of Current Behaviors
“Showed me what I want to be in life…what I really like and stuff.” Slide27
Limitations:
Rather than taking videos of current life,
young men tended to just sit and talk to
videos—Cameo performances Not as creative as anticipated.Some young men needed encouragement to express themselvesOthers “overexpressed.” Slide28
Conclusions
Video Journaling provided a medium for accessing rich data from young men. This is especially true with regard to the:Sensitive nature of the
dataActive engagement in daily technology and social mediaV
arying levels of verbal expressiveness of teens. Video journaling may be an effective method to provide voice to marginalized populationsSlide29
Examining Survivors of Cancer and Physical Activity
in Delaware (ESCAPADE):
A Community Based Participatory Research Needs Assessment
Michael Mackenzie PhD
1, Sean Hebbel MSW2, Ines Crato BS1, Lanie Pires1, Scott Siegel PhD3
1
Department of Behavioral Health & Nutrition, University of Delaware
2
Cancer Support Community Delaware
3
Helen F. Graham Cancer Center & Research InstituteSlide30
Introduction
Delaware seeks to be among states ranked lowest for cancer incidence and mortality, to eliminate cancer health disparities, and ensure quality cancer care for all Delawareans.
Higher physical activity levels associated with better cancer prognosis, reduced mortality, and improved psychosocial and quality of life outcomes.
Despite reported physical activity benefits, majority of cancer survivors do not meet required minimum recommendations.
SSlide31
Research Goal
Develop community-based physical activity needs assessment specific to Delaware cancer survivors and service providers utilizing a community-based participatory research (CBPR) approach.
SSlide32
Specific Aims
Assess collective
awareness and knowledge regarding associations between physical activity and
cancerAssess existing physical activity programs and services available to Delaware cancer survivors
SSlide33
Engagement Plan
Generate novel data focusing on physical activity in cancer survivorship while developing community-academic partnerships.
SSlide34
MethodsUsing CBPR approach community partners were engaged
Individuals recommended by the community partners were contacted and semi-structured interviews were conducted. Individuals would then recommend additional individuals to be interviewed.Individual Interviews (41: 28 service providers, 13 cancer survivors)Focus groups (2: 6 service providers, 6 cancer survivors)
MSlide35
MethodsInterviews transcribed then coded into separate themes using NVivo software.
Responses and themes initially analyzed by research coordinator and research assistantThemes then analyzed in collaboration with principle- and community-investigatorsFindings then presented to focus groups for verification and expansion of findings
MSlide36
FindingsFive key themes identified:Cancer Community
KnowledgeServicesNeeds & IssuesAction Plan
SSlide37
1. Cancer Community
SSlide38
2. Knowledge
MSlide39
3. Services
MSlide40
4. Needs and Issues
SSlide41
5. Action Plan
More focus/awareness on existing programs and introducing a new role of a navigator for healthy lifestyle components of cancer survivorship.Raise awareness of available programsPossible new role: Health lifestyle specialist-coach with cancer-specific trainingOncologists and other health providers must be on board (screening, referring for physical activity)
Insurance coverage for healthy lifestyle programs
SSlide42
Knowledge of key local factors used to:Identify physical activity and cancer care priorities in State of DelawareGuide development of strategies to improve quality of physical activity in cancer careCommunication, coordination, and delivery to cancer survivors and their support networks. Develop practical recommendations for subsequent action-oriented research
State-wide large-scale physical activity surveyClinical interventions and health promotion efforts across cancer survivorship continuum Future Directions
MSlide43
Acknowledgements
The investigative team gratefully acknowledges the support of our respective institutions and the Delaware-CTR ACCEL Community Engaged Research Award supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Binder-Macleod).
SMSlide44
Assessing the Value of Community Health Workers in Delaware
A Community Based Participatory Research Approach
Brian Rahmer, PhD, MS; Nora Katurakes, MSN, RN, OCN; Venus Jones; Luisa Ortiz-Aponte, BA; Trincia Griffin; Grecia CaceresSlide45
Supported in part by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Binder-Macleod).Slide46
Healthcare Environment
30% of traditional Medicare payments to alternative payment models
85% of traditional Medicare payments to quality or value
Accomplished by end of 2016.Improve the overall quality of care by making health care more person-centered, reliable, accessible, and safe.Improve Americans’ health by supporting proven interventions to address behavioral, social, and environmental determinants of healthReduce the cost of quality health care for individuals, families, employers, government, and communities. Slide47
Regulatory EnvironmentCMS rule change allows Medicaid to reimburse for covered preventive services provided by unlicensed practitioners—such as CHWs—as long as a physician or other licensed practitioner recommends the services.
States must amend their state plans in order to take advantage of the rule change, and amendments must include qualifications for non-licensed practitioners. State SIM funding and DCHI focus on CHW education and training, integration into workforce, coordinationHealthy Neighborhoods and various community health improvement initiatives…Slide48
Community EnvironmentPersistent, structurally resistant child & family povertyGrowing inequality, adversity, disembodiment
Rapidly changing epidemiology, slowly adapting systemsDominance of adult-focused, cost-driven policy, & market driven reforms based on consumerismIntractable gaps – infant mortality, child morbidity, school readiness, high school graduation, unemployment, etc.Incremental, ameliorative mindset in face of problems that demand audacious, transformative changeSlide49Slide50
What did we do?Gain important knowledge directly from patients, families and communities, about how they perceive the “value” of Community Health Workers (CHWs) within the context of their own lives.“Value” may mean different things to different people and we wish to learn more about how patients perceived the value of CHWs.Slide51
Why did we do it?“Value” is a dynamic term. When value is defined in institutional setting, evidence shows it may miss the voice of the patient, family and community.Rules, resources, regulations, governance, accountability and context by which CHW efforts evolve, are explicitly driven by who gets to define valueSlide52
How did we do it?Included people currently doing CHW work to help us engage in a series of conversations across the state with patients, families, and stakeholders who have worked with CHWs.
Systematically poured through the language of these conversations as a team, to identify points, themes, messages, and context.DEPICTCultural Historical Activity Theory (CHAT)Partnered with CHWs to help us verify the importance of these findings and whether or not they reflect the experience of CHWs in the field.Slide53
CHAT & Activity Systems AnalysisManageable unit of analysis, even with shared objectivesSystemic implications, transformative practiceSystemic focus on contradictions and tensions
Communicating findings in deliberate, targeted way
(Engeström, 2001; Stetsenko, 2010)Slide54
Cultural-Historical ActivitySystem as
unit of analysisMulti-voicedness: always a community of multiple points of views, traditions and interests.Historicity: take shape and get transformed over time. Potentials and problems can only be understood against the background of their own histories.
The central role of contradictions as sources of change and development.
Activity Systems' possibility for
expansive transformation (cycles of qualitative transformation): when object and motive are reconceptualized a radically wider horizon opens up.Slide55Slide56
Trust as a moderator against precarity“Being able to
get your hands on them when you absolutely need them…” “Just a phone call away, not having to be put on hold and listen to that music…”“When I contact them by phone or text, and they get right back to me… that means everything.”“They are very responsive…”“It
is not a burden if you need help.”Slide57
Reimagining the commons… with CHWs“You have someone that you can depend on. She would even tell me that I can text or call her at any time.”
“It’s good to know you have somebody there for you when you don’t have anybody at all.”Knowing that somebody cares and having them in your corner - she makes me feel comfortable and confident…She helped me with my self-esteem. Certain things that I’ve shared with her, she’s helped me with overcoming.Slide58
Value: Core Thematic RelationshipsSlide59Slide60
CHW Stewardship of Community HealthSlide61
What should we focus on?Promote the correspondence between CHW goals and those of the community.
Stimulate a feeling of shared experience and collective identity among CHWs.Promote the value of achieving equity goals to the CHW collective.Promote the link between health care transformation objectives and the distinctiveness of the CHW collective in helping move the equity needle.Focus on what is within the CHW’s power to deliver and allow CHWs collective agency to thrive and learn from one anotherSlide62
Key Policy ImplicationsState and federal policymakers increasingly look to CHWs to increase health equity in transforming health care systems.
Policymakers and leaders would benefit from greater communication about and understanding of one another’s cross-agency efforts to enlist CHWs in reducing health disparities and incorporate CHWs into state demonstration programs.Tension exists between states’ and institutional desire for flexibility in defining CHW roles and the federal need for a uniform definition to catalyze training funds and data collection.Responsibilities should fit with salary and other benefitsManagers, professional health workers, CHWs themselves, and community members should all be clear about what is expected from CHWs.Slide63
Key Policy ImplicationsLong‐term, sustainable financing mechanisms are critical.Community participation—in deciding what duties CHW should assume and how they will be selected, trained, recognized, supported, supervised—integral part of capacity.
Community provides legitimacy to the CHW, which brings credibility to the preventive and health promotion activities of healthcare transformationFostering the development of interpersonal, institutional, and community trust is critical for effective CHW programs. Context‐ specific expectations of CHWs in alignment, and policies & resources enable these expectations to be met.Equity considerations are paramount in structuring community engagement to prevent co‐optation by powerful institutional demands.Ensure that the interests of women and children are represented adequately.CHW programs inherently tap into the community’s reservoir of good will, volunteerism, and desire to help others in the community, and self‐interest for the benefit of CHW programs.Politics of collectivism and solidarity are our most effective tool in combating ill health and health inequalitiesSlide64