Introduction
As North Carolina passes the halfway point in the 2020s, the state faces an opportunity to reflect on Healthy North Carolina 2030 (HNC 2030), key health indicators, and the goals the initiative set for the end of the decade. Many of the key health indicators in HNC 2030 involve non-medical drivers of health, aspects of overall health and well-being that community health workers (CHWs) are uniquely equipped to navigate.
In this interview, Honey Yang Estrada, President of the North Carolina Community Health Worker Association (NCCHWA), joined Brady Blackburn, Managing Editor of the North Carolina Medical Journal, for a conversation about CHWs, the important roles they fill in North Carolina’s health ecosystem, and how they can impact access to healthy food.
The NCCHWA was founded in 2021 to serve community health workers across the state. Estrada, who was the organization’s first employee, outlined the work the NCCHWA does training and certifying CHWs, advocating for workforce needs, and broadly supporting the profession and the people who work within it.
Reflecting on the indispensable role of CHWs, Estrada spoke about how important it is for people to see the field as a terminal career. She also discussed the importance of funding to ensure people have stable job opportunities, and she talked about integration of CHWs into broader medical systems, straddling institutional health care spaces and neighborhoods, backyards, and other community spaces.
On the topic of food, Estrada spoke about how important food is to people from a cultural perspective as well as a health perspective. “…as we’re talking about food, ‘food’ is so much, right? Food is celebration. Food is reward. Food is emotion,” she said. “There is so much about food that impacts our communities. One of the things that I really want to push on here is the fact that CHWs really can be the access point to healthy food, especially as we’re thinking about culturally relevant foods.”
This interview has been edited for length and clarity. Click here to listen to this interview.
Brady Blackburn: Honey, thank you so much for joining us today for an interview. To start us off, I wanted to see if you could just introduce yourself and tell me a little bit about the work that you do, and the work that the North Carolina Community Health Workers Association does.
Honey Yang Estrada: Yeah, absolutely. Thank you, Brady, for having me. My name is Honey Yang Estrada. I am a proud community health worker. I’ve been doing this work for—it seems like all my life—but I’ve been doing this work for quite some time and have the great honor of leading the North Carolina Community Health Worker Association, where it’s all things CHWs, all the time.
We’re very proud at the North Carolina Community Health Worker Association, where we get to lead all efforts in regard to advocacy, credentialing, training, and sustainability for CHWs. The Association has been in existence for quite some time. We were founded in the spring of 2021, and I became its first employee in early 2022.
Since then, we’ve worked really hard to lay the foundation for really robust training standards. We’ve partnered with the community college system, where our standardized core competency training is delivered through, I think we’re up to about 18 colleges now, that deliver the curriculum. And that curriculum, once completed, CHWs are eligible for certification. To date, we have approximately 1,200 CHWs who have been certified in almost all 100 counties across North Carolina, and we’re really proud of those efforts.
We’ve also worked really hard to build a system where CHWs can advance in their careers, because we really want CHWs to understand that being a community health worker is and can be a terminal career. So, we’re really proud in North Carolina that we’ve built what we call advanced levels of certification that really allow for CHWs to grow in their field, to grow professionally, and really, it’s an opportunity for upward mobility.
We also have 6 really established CHW regional networks across the state, and this really allows CHWs to engage with us. I get to work with a phenomenal team of CHW leaders who are very passionate about this work. I’m really proud of all of the work that they’ve led in North Carolina. And, you know, I might be a little bit biased here, but I will say that when it comes to CHWs, North Carolina is a leader across the country.
Brady Blackburn: Wonderful. I’m wondering if you can tell me just a little bit about what community health workers are, what they do, and what makes them such a vital part of North Carolina’s health system.
Honey Yang Estrada: You know, I love this question, Brady, because if there’s one thing I can talk about all day, it is community health workers. As we think about the definition of community health workers, as defined by the American Public Health Association, we are frontline public health workers who are trusted members of our community, meaning we look like our communities.
We speak the same language, we eat the same food, we share the same faith. This trusting relationship allows us to serve as a link, a liaison, an intermediary, as we think about building those connections between health and social systems and community.
This is why CHWs are so critical when we’re thinking about the health system. All of these things are really, really critical when we think about whole-person health.
One of the things that I love to talk about is how this trust is so critically important because, let’s face it, white coat syndrome is a real thing. I get that, right? When I go into my physician’s offices, my blood pressure is up a little bit. I’m a little bit nervous. So, when we bridge this with bringing on and partnering with community health workers who can hold a community member’s hand in the presence of a physician—in the presence of that health care team—it helps to really alleviate a lot of that fear, a lot of that nervousness, and allow that really rich connection that we’re really looking for.
Brady Blackburn: Thank you, and I want to dive a little bit more into that trust aspect that you were talking about, and just why it’s so important to have these folks working in the communities that they are an active part of. So, can you tell me a little bit about how community health workers in that context can bridge gaps between the communities they serve and those clinical providers?
Honey Yang Estrada: Absolutely. One of the things that I say in my spheres of influence is that the clinical team can only see what’s within those four clinic walls, right? But when we think about the community health worker, because the community health worker is a trusted member of the community, they get the invitation to the dinner table. They get the invitation to the birthday parties. They get the invitation to the family barbecues. So, because of that trusting relationship, they’re going to tell us things that they might not tell that clinical provider.
We get to see things outside of that clinic that might impact that person’s health. One of my favorite stories that I talk about time and time again—this is a real story—is about a community health worker who went to visit a patient. She was working at a local clinic. This patient had missed a couple of appointments, and she was doing some outreach. As it turns out, this family was experiencing black mold. So, as a mom, this patient is not worried about going to the physician for her doctor’s appointment. She’s worried about making sure that she can keep her house clean, because her children are experiencing asthma from black mold. Those things would never have been identified just within the four-clinic walls. It took that community health worker doing that outreach to understand what was going on in the home, how that is impacting her life and her experience, and why she was missing appointments.
And on top of that, you know, for CHWs, one of the cornerstones of our profession is lived experience. That lived experience is so critical to who we are and to what we do. When we’re talking about that trust that I just mentioned, if I’m a community member and I’m working with a CHW who has the same lived experience as I do, their lived experience helps me to understand, oh my goodness, this person knows me. This person has seen the things that I’ve seen. This person has lived through the things that I have lived through. So, not only is there sympathy, but there is empathy. There is an understanding of who I am as a person, and not just trying to get me through this treatment plan and checking this box, or taking that med. This person sees me and understands what I’ve been through, and this is why CHWs are so critical when we’re thinking about teams-based care.
Brady Blackburn: So, zooming out a little bit, as an organization that works statewide, you see a lot through the North Carolina Community Health Worker Association, but I wanted to talk a little bit about funding and what your job looks like in 2025. Many parts of North Carolina’s health ecosystem have experienced a lot of funding changes over the past year, and I’m curious for you, how has this impacted your organization, community health workers, and the organizations that employ them? What challenges do you see on the immediate horizon?
Honey Yang Estrada: Yeah, it’s been tough. We have seen what we call a boom and bust of funding over the years. Community health workers, historically, as a profession, have done a lot of work for free or on a volunteer basis. A lot of times, we are unpaid, and it is this boom and bust of funding where, okay, we get this grant, and it pays for a year or two, and then the job is over.
It’s really hard, you know. During the pandemic, there was a huge spotlight shone upon community health workers. We saw the greatest surge in community health workers across the country. Earlier this year, the clawback of a lot of public health dollars really impacted CHWs and CHW programs. We saw lots of CHWs who were laid off, contracts that were terminated. When we think about CHWs, the majority of community health workers are women of color. Women of color who come from disparaged communities. Women of color who they themselves are experiencing disparities. So, what we’re seeing is, because contracts are terminated, because funding is cut, we’re seeing this cycle perpetuated, where communities no longer receive the support that they need. And it’s really harmful.
I think that as we’re thinking about the challenges and how that impacts communities, CHWs are leaders within their communities, and so when they are not receiving the resources or the care that they need, how do we expect them to also support the communities that they have been supporting for all their years? One thing that I do know is that CHWs and communities are resilient, and they find a way. They find a way to make it work, but these workarounds don’t always work, and it’s very harmful. So, when we’re thinking about the challenges that are on the horizon, I’m really nervous about what the funding is going to look like in the future.
I will also say that I have so much hope in community health workers, because this is a profession that has continued to survive regardless of what the funding landscape looks like. We continue to show up, we continue to do the work. That’s because if you talk with community health workers, they will tell you, community health workers were born. We were not made, we were born.
Brady Blackburn: Absolutely. So, I want to dive in a little bit more to that boom-and-bust cycle you mentioned. What challenges do community health worker programs face when that funding is less predictable, especially in the short term? When funding is short, we know what that means. That means you can’t pay as many community health workers, but I imagine also on the boom side, when the funding floods in, especially after a bust period, that can also prove to provide its own challenges.
Honey Yang Estrada (section shortened and edited for clarity): One of the things that we saw during the COVID-19 pandemic was a boom in funding for CHWs and CHW programming. We saw a lot of organizations step up and support CHWs, and that was fantastic. With that boom also came challenges. Some organizations don’t quite understand the community health worker role, so they began hiring people with that title even though their work did not truly reflect the CHW profession. We have had lots of conversations within the CHW field about what this means for the integrity of our profession. Because, for those of us who have been doing this work for a long time, it can be tough to watch folks who come on the scene and then go when the money dries up.
As funding becomes less predictable in the future, my concerns are, what does it mean for the current profession and the folks who are working in it? It means that not only do we hurt, but communities hurt. It’s perpetuating this system that we continue to see.
We have hospital and health systems, and CHWs are doing great work to help them meet their quality scores and those health equity goals that they’re working so hard to achieve. When these positions are cut due to funding gaps, these same organizations are then going to struggle to meet those measures.
The boom and bust hurts everybody, and so it’s really challenging to see what this current landscape has done.
Brady Blackburn: Absolutely. So it sounds like it’s a dollars and cents question of who can we hire and how can we keep them employed, but also almost a peer education question of how do we sustain this industry in a way that allows the people who could be employers to, A) understand what community health workers are, B) understand their importance, and C) see those workers making a difference and understand what longevity there means to the community.
Honey Yang Estrada: Absolutely, yes, 100%.
Brady Blackburn: So, changing gears just a little bit, I know community health workers are particularly important when it comes to helping people access social services in addition to direct healthcare. In this vein, I’d like to talk a little bit about healthy food. At the North Carolina Institute of Medicine and with the North Carolina Medical Journal, we’re taking the time to look at all of the different health indicators in Healthy North Carolina 2030 as we were rounding out this halfway point in the decade. One of those indicators is access to healthy food, something that can significantly impact people’s overall health and well-being. Can you just tell me a little bit about how community health workers can help expand access to healthy and affordable food?
Honey Yang Estrada: We saw a lot of this during the Healthy Opportunities Pilots, where CHWs were working to bridge access from communities to healthy food. Healthy food is just one of those health-related social needs that we talk about so often in our field. And what else I’ll say here, as we’re talking about food, “food” is so much, right? Food is celebration. Food is reward. Food is emotion. There is so much about food that impacts our communities.
One of the things that I really want to push on here is the fact that CHWs really can be the access point to healthy food, especially as we’re thinking about culturally relevant foods. Not all communities have access to culturally relevant foods, and this is one area where CHWs do really well. I know that community health workers have absolutely advocated to food banks and food providers to think about the foods that they’re providing for communities and how they can respond in a way that is culturally relevant to the communities that they’re serving.
I love to see what’s happening with the Healthy Opportunities Pilots. We had communities accessing culturally relevant foods, which makes me think about my grandmother. I’m an Asian woman, you know, and [my grandmother] went to a food pantry. My mom took her to a food pantry once, and they got beans. In our culture, we don’t traditionally eat beans, and she looked at me, and she was like, what am I supposed to do with this? And I’m like, great question! So, when we’re seeing CHWs advocate for communities to think about what culturally relevant food means, it is such a breath of fresh air to see those dots be connected and for communities to get not just food, but food that is valuable and substantial for them.
Brady Blackburn: That makes a lot of sense and I imagine, even just beyond nutrition, especially when you’re talking about culturally relevant food, it is something that helps strengthen family bonds and strengthen community bonds, which are both important factors that impact people’s health.
Honey Yang Estrada: Mm-hmm, absolutely. Yes, for sure.
Brady Blackburn: So, I’m curious if you have an example you’d like to share about a community health worker program or a program that involves community health workers that is actively helping to improve food security in North Carolina.
Honey Yang Estrada: Oh, my goodness, there are so many. Where do we start? Where do we stop? Oh, my goodness. So, I know that there are a ton of programs out there. I’m not going to name names, but one that I’ll talk about is centered around diabetes, and this community health worker was serving as a coach for folks that are living with diabetes. Because the population she was working with was primarily Spanish-speaking, she was able to really spin the program in a way, here again, that was really culturally relevant.
I think part of this is because, if we think about the traditional, conventional American diet, if I’m a Spanish-speaking person, you’re telling me I can’t eat tortillas, and I can’t eat beans, right? And so, there’s all of these things that I can’t eat. But what this community health worker did was she spun it around so that they could include those culturally relevant foods that are so important to a part of who they are, and still meet their health goals. And thinking about, you know, access to food and improving not just food security and where they can get these ingredients to support their lifestyle, but then how this would translate to healthier goals and results. Oh my goodness, it was so beautiful, and I was so excited to be a witness to all of that. But that’s just one example of how CHWs are so critical in programming, when we’re thinking about not just healthy foods, but all health-related social needs.
Brady Blackburn: Absolutely, thank you for sharing that. So, in addition to being really, incredibly thoughtful about how to bring food and the right food to individual communities, I’m also curious how community health workers go about identifying food insecurity, especially when it shows up as a barrier to something like managing a chronic condition like diabetes or hypertension.
Honey Yang Estrada: Absolutely. So, you know, I shared the story a little bit earlier about how CHWs get the invitation to the dinner table and to the family cookouts, right? And it’s because we have those trusting relationships. When we get into people’s homes, we can see things. Again, community health workers are going to see things that the clinical team will never see.
And because we get those invitations, we’re able to do a 360-degree review of what’s actually going on in the home. There are countless stories of CHWs who have done just that when they go into a patient’s home or a community member’s home. They’re able to do a little bit of an assessment and understand what the needs are of that family and what the priorities are. Is it food? Is it water? Is it clean air? What is it? Is it clothing? Is it medicine? What is it that they need? And again, that trusting relationship gives them access into the home where they’re going to be able to see all the things that are needed, all the things that are lacking, and then be able to continue to think about which resources we can bring in to support that family to get them back to a place where they’re not just surviving, but that they’re thriving.
Brady Blackburn: Great, thank you. As we wrap this interview up, I want to ask you about the bigger picture for community health workers. So, zooming out from this specific example of food access, you’ve talked a bit about this relationship aspect of community health workers. I’m curious how, looking at food access as an example, you would talk about community health workers and how they build relationships and local infrastructure that accounts for the whole person within our health care system.
Honey Yang Estrada: Oh, my goodness, yes. So, you know, food access is just one piece of the puzzle. I think that when we’re looking at food access, it [contributes] to so much more than that. I said it before, right? Food is reward. Food is celebration. Food is emotion. When we put all of that together with all the health-related social needs, there’s so much that we can think about to get to whole-person health.
As we think about those health-related social needs, the social determinants of health, where a family or where a community member is living, and how they access that is going to be so critical to think about the bigger picture of community health. If it were up to me, every single neighborhood would have a community health worker to really support this holistic, whole-person health that could get us to the true, healthy communities that we really want to see.
Brady Blackburn: Great. Well, thank you so much, and thank you for taking the time to talk with me today for the North Carolina Medical Journal.