The social determinants of health continue to impact health disparities among communities living along the U.S.-Mexico border. Because community health workers (CHWs) are recognized for promoting a variety of positive patient-centered health outcomes in their roles as educators and health system navigators, recent inquiry has focused on the role of the CHW in facilitating community-level changes through grassroots advocacy to impact the social determinants of health. Social capital theory, which posits that participation in groups has positive consequences for individuals and the community, is a useful lens through which CHW effectiveness in grassroots advocacy can be measured and replicated. Using quantitative and qualitative methods, this study investigated the social capital characteristics of fifteen CHWs working in border communities who were trained in grassroots advocacy. Participating CHWs reported high baseline levels of social capital, which was assessed using a social capital questionnaire. After one year of engagement in grassroots advocacy, participating CHWs reported statistically significant increases in one measure of bridging social capital (community engagement) and one measure of linking social capita (participation with political/civic leaders). Qualitative interviews with each CHW further explored the role of social capital in their grassroots advocacy, resulting in a social capital model elucidating six activities of CHW-driven grassroots advocacy. The mixed methods results provide measures for assessing CHWs' social capital in their traditional roles and as grassroots advocates, as well as a framework for understanding how CHWs use their social capital to take grassroots action addressing the social determinants of health.

This dissertation is about Indigenous and settler health, wellbeing and health policy in rural Manitoba. Across Canada, both sweeping and incremental provincial health system changes have profound effects on marginalized communities facing existing health inequities, including rural settler and Indigenous peoples. Increasingly, the centralization of provincial health care systems has led to the elimination of health services within rural settings. The research I present in this dissertation arose from advocacy efforts in a rural community in southwest Manitoba. The community sought representation and recognition in health decision-making in the midst of the largest health care system transformation in provincial history and called for local research production. The community-led study grew to the larger inquiry and analysis presented here, including a First Nation and Métis community, which were both affected by the transformation. The objectives of this dissertation were to analyze the ideas and structures used to inform provincial decisions, and to understand community experiences of rural health care before and during system transformation. As a settler researcher, I undertake an anti-colonial, strengths-based, community-engaged approach to research, developed through ongoing relationship with the community. In addition to a critical thematic analysis of key policy documents, semi-structured interviews were conducted with settler, First Nations, and Métis community members and service providers regarding their experiences within the health care system, their perceptions of change and the impacts of transformation on health and wellbeing. Arising themes include the importance of relational health care relationships in determining wellbeing, and the sense that the government undertook dehumanized decision-making in developing and implementing health system change. This dissertation concludes with policy recommendations for provincial governments, including the prioritization of community voices, and the visibility and involvement of rural and Indigenous peoples in health system decision-making. / Thesis / Doctor of Philosophy (PhD)