abstract: The health situation of indigenous peoples is comparable to that of the world's poorest populations, but with the additional burdens of social and cultural marginalization, geographic and cultural barriers to accessing health services, and, in some areas, appropriation of land and natural resources. Cultural transmission (the transfer of beliefs, ideas, and behaviors from one culture to another) from outsider health institutions should presumably aid in closing this health gap by transferring knowledge, practices, and infrastructure to prevent and treat disease. This study examines the biosocial construction of the disease ecology of tuberculosis (TB) in indigenous communities of the Paraguayan Chaco with varying degrees of cultural transmission from outside institutions (government, religious, and NGOs), to determine the influence of cultural transmission on local disease ecologies. Using a biocultural epidemiological framework for the analysis of human infectious disease ecology, this study employed an interdisciplinary, mixed methods approach to examine the interactions of host, pathogen, and the environment in the Paraguayan Chaco. Three case studies examining aspects of TB disease ecology in indigenous communities are presented: (1) The effective cultural transmission of biomedical knowledge to isolated communities, (2) Public health infrastructure, hygiene, and the prevalence of intestinal parasites: co-morbidities that promote the progression to active TB disease, and (3) Community-level risk factors for TB and indigenous TB burden. Findings from the case studies suggest that greater influence from outside institutions was not associated with greater adoption of biomedical knowledge of TB. The prevalence of helminthiasis was unexpectedly low, but infection with giardia was common, even in a community with cleaner water sources. Communities with a health post were more likely to report active adult TB, while communities with more education were less likely to report active pediatric TB, suggesting that healthcare access is the major determinant of TB detection. More research is needed on the role of non-indigenous community residents and other measures of acculturation or integration in TB outcomes, especially at the household level. Indigenous TB burden in the Chaco is disproportionately high, and better understanding of the mechanisms that produce higher incidence and prevalence of the disease is needed. / Dissertation/Thesis / Doctoral Dissertation Social Science and Health 2014

A discriminação étnico-racial é um evento estressor capaz de produzir múltiplos danos físicos e mentais. Apesar do crescente interesse científico mundial e de ser tema estratégico para a saúde coletiva, permanece pouco estudado no Brasil, especialmente quando comparado aos EUA, responsável por expressiva produção acadêmica nessa área. Acerca das comunidades remanescentes de quilombo, são ainda mais escassos os dados disponíveis na literatura sobre a sua situação de saúde, sendo nula a investigação abrangendo discriminação étnico-racial entre esses indivíduos. Buscando contribuir para essas questões, a presente pesquisa analisou as frequências de discriminação entre os adultos quilombolas do município de São Lourenço do Sul/RS, por intermédio da escala Experiences of Discrimination, além de verificar as condições sociodemográficas e de saúde dessa população, mensurados pelos questionários da Pesquisa Nacional de Saúde adaptados para esse trabalho. Foram realizadas 103 entrevistas, sendo a amostra composta por 55,3% de mulheres, 71,8% com idades entre 18 e 59 anos e 72,8% da raça/cor preta. A prevalência de discriminação étnico-racial percebida em algum momento da vida foi de 59,2%, resultado superior ao encontrado em outros estudos importantes acerca do tema no país. As frequências com que os entrevistados reportaram ter sofrido discriminação nos contextos cotidianos investigados variaram de 1,9% ao pedir crédito ou empréstimo bancário até 28,2% ao frequentar a escola. Os itens acerca de agravos em saúde revelaram alta (64,1%) frequência de doenças crônicas, sendo a hipertensão arterial sistêmica (45,6%) a doença mais prevalente. Foram baixos os índices de tabagismo e de uso abusivo de álcool. Os resultados desse estudo permitem concluir que a prevalência de discriminação racial nas comunidades remanescentes de quilombo do município de São Lourenço do Sul foi alta e o local no qual ela foi percebida com maior frequência foi o ambiente escolar. É de suma importância que se reconheça a existência da prática do racismo dentro da sociedade brasileira para que se sistematizem ações para transformar essa realidade. / The ethnic-racial discrimination is a stressor event related to multiple physical and mental damages. However, despite the growing scientific interest in a global scale, it remains little studied in Brazil, especially when compared to the USA, responsible for expressive academic production in this area. Concerning the remaining communities of quilombo, the data available in the literature about their health status is even scarcer, with no research covering ethnic-racial discrimination on these individuals. In order to analyze these questions, the present study investigated the frequencies of discrimination among quilombola adults in the city of São Lourenço do Sul / RS, through the scale “Experiences of Discrimination”, beside verifying the sociodemographic and health conditions of this population, measured by questionnaires of the National Health Survey adapted for this work. A total of 103 interviews were conducted, with 55.3% of women, 71.8% between 18 and 59 years old, and 72.8% of blacks. The prevalence of ethnic-racial discrimination perceived at some point in life was 59.2%, a result superior to that found in other important studies on this matter in the country. The frequencies with which respondents reported discrimination in the daily contexts of the questionnaire ranged from 1.9% when applying for credit or bank loan up to 28.2% when attending school. The items about health problems revealed a high (64.1%) frequency of chronic diseases, with systemic arterial hypertension (45.6%) being the most prevalent disease. The rates of smoking and alcohol abuse were low. The results of this study allow us to conclude that the prevalence of racial discrimination in the remaining communities of quilombo in the municipality of São Lourenço do Sul was high and the place where it was most frequently perceived was the school environment. It is extremely important to recognize the existence of the practice of racism within Brazilian society to systematize actions to change this reality.

This dissertation thesis titled ``Social Determinants of Health in Selected Romany Communities{\crqq} adverts to the issues of relationship between the health condition and social and economic factors, as well as other external or culture-conditioned influences affecting them. I have based my work on the concept of ten social determinants of health by Wilkinson and Marmot (2005). The theoretical section adverts to the interrelation of particular determinants in the Roma communities and the specific role of stress affecting all determinants. Thereat, I have based my study on generally available findings, primarily those acquired from research surveys, against which I have compared the results of my research section. The objective of this presented thesis is to describe the influence of social determinants of health in the wider context of everyday living in selected Roma communities. In doing so, I have primarily focused on impediments to the full participation of the described target population in the living of the majority society due to social exclusion. The target population consists of five multi-generation Romany families from two separate locations. Two families enjoy a higher stratification status (including a representative of the Romany elite) and three live in socially excluded locations. Having considered the specifics of the target population and orientation on the common day of the respondents, I have opted for socio-ethnographic field research, i.e. a qualitative by a research method, with the prevailing technique being participative observation and interviews. Processed research data is presented, alongside discussions, in subchapters following upon the topics of the theoretical part of my thesis, i.e. particular groups of health determinants. The results indicate that it is not only the underprivileged socio-economic conditions that take a share in the worsened health condition of persons living in socially excluded locations but these also involve therefrom originating stressors, which are often specific (symbolic element of social exclusion, alternative sources of livelihood). I also attribute a special meaning to culture-conditioned norms and opinions that, in some cases, bear a negative influence on the health condition via behavioral factors (such as a low number of Roma mothers lactating their children or attitude to the abuse of habit-forming substances). Apart from the identification of the influence proportions breakdown by social determinants of health in Roma communities, I see the benefit of my thesis in its qualitative nature, predestining it for utilization in a wider, longitudinal quantitative research of the target Romany group.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / EvidÃncias mostram que indivÃduos com piores condiÃÃes de saÃde sÃo os mais pobres, com menos escolaridade e piores condiÃÃes de vida. A UtilizaÃÃo dos ServiÃos de SaÃde (USS), determinante social intermediÃrio, pode interferir na saÃde dos indivÃduos. No entanto, a busca dos serviÃos de saÃde depende das caracterÃsticas pessoais, dos recursos disponÃveis e da percepÃÃo da necessidade de saÃde segundo o Modelo Comportamental de USS proposto por Andersen. O objetivo do trabalho foi identificar os fatores associados à USS entre crianÃas de 5 a 9 anos na zona urbana do municÃpio de Sobral-CE. O estudo foi um recorte da pesquisa de base populacional âEstudo das condiÃÃes de saÃde, educaÃÃo e qualidade de vida das crianÃas de 5 a 9 anos da zona urbana do municÃpio de Sobral-CEâ. Foram realizadas entrevistas domiciliares com 3.274 crianÃas, em 1999/2000. As variÃveis dependentes foram a USS nas unidades de saÃde da famÃlia (PSF), nos hospitais e nos consultÃrios particulares e conveniados aos planos de saÃde, nos Ãltimos 30 dias e de forma regular. Apenas 558 (17,0%) das crianÃas utilizaram os serviÃos de saÃde nos Ãltimos 30 dias. Quando perguntado o tipo de serviÃo utilizado habitualmente, o PSF foi o mais referido (79,1%), seguido do hospital (13,5%) e dos serviÃos por convÃnio ou particulares (3,4%). Em torno de 116 crianÃas, 3,5% da amostra, eram levadas a outros serviÃos como farmÃcias, rezadeiras, madrinhas, avÃs, entre outros. Os fatores associados à USS no Ãltimo mÃs foram: a ocorrÃncia de problemas de saÃde (OR=3,9); a utilizaÃÃo regular do PSF (OR=1,8); a coleta do lixo, direta e indireta (OR=1,3 e 1,9) e a localizaÃÃo da residÃncia na sede do municÃpio (OR=1,5). Os fatores associados à utilizaÃÃo regular do PSF foram: escolaridade materna e condiÃÃes econÃmicas menores, morar na sede dos distritos e prÃximo ao PSF, realizar consulta sempre ou Ãs vezes no mesmo dia da procura, ser cadastrado no PSF e nÃo ter plano de saÃde. Associados ao hospital foram: escolaridade materna e condiÃÃes econÃmicas maiores, morar na sede do municÃpio e distante do PSF, melhores condiÃÃes de escoadouro de dejetos, realizar consulta sempre no mesmo dia da procura, nÃo ser cadastrado no PSF e nÃo possuir plano de saÃde. Associados aos consultÃrios particulares/conveniados foram: escolaridade materna e condiÃÃes econÃmicas maiores, nÃo ser cadastrado no PSF e possuir cobertura de plano de saÃde. Os resultados mostraram que a USS no municÃpio de Sobral-Ce praticamente nÃo mostrou desigualdade no acesso entre a faixa etÃria estudadas. Atribui-se a implantaÃÃo da EstratÃgia SaÃde da FamÃlia que alcanÃou os grupos populacionais mais vulnerÃveis e historicamente excluÃdos da atenÃÃo à saÃde. / Evidence shows that individuals with worse health conditions are poorer, less educated and poorer living conditions. The Health Services Use (HSU), a social determinant intermediary, can interfere with the health of individuals. However, the pursuit of health services depends on personal characteristics, available resources and the perceived need for health according to the Behavioral Model of HSU proposed by Andersen. The objective was to identify factors associated with HSU among children 5 to 9 years in the urban area of Sobral, CE. The present study was part of a research population-based "Study of the health, education and quality of life for children 5-9 years of the urban area of Sobral-CE". Home interviews were conducted with 3,274 children in 1999/2000. The dependent variables were the HSU in family health units (PSF), in hospitals and private clinics and insured health plans in the last 30 days and regularly. Only 558 (17.0%) children used health services in the last 30 days. When asked what type of service commonly used, the PSF was the most frequently mentioned (79.1%), followed by hospital (13.5%) and services by private agreement or (3.4%). Around 116 children, 3.5% of the sample were taken to other services such as pharmacies, mourners, godmothers, grandmothers, and others. Factors associated with HSU in the last month were: the occurrence of health problems (OR = 3.9), regular use of the PSF (OR = 1.8), garbage collection, direct and indirect (OR = 1.3 and 1.9) and location of residence in the town (OR = 1.5). Factors associated with regular use of the PSF were maternal education and lower economic conditions, living in the headquarters district and close to the PSF, conduct consultation always or sometimes the same day seeking to be registered with the PSF and not have health insurance. Associated with the hospital were: maternal education and higher economic conditions, living in the town and away from the PSF, better outlet for waste, carry out consultation on the same day of demand, not registered in the PSF and do not have health insurance. Associated with private offices / insured were maternal education and higher economic conditions, the PSF is not registered and has health plan coverage. The results showed that the HSU in Sobral-CE showed almost no inequality in access between the age group studied. Is attributed to the implementation of the Family Health Strategy which reached the most vulnerable populations and historically excluded from health care.

Master of Public Health - MPH / Background: Parental perceptions of health and child health needs have not been explored within Early Childhood Care and Development (ECCD) centres in the Eastern Cape of South Africa. Although the relationship between social, economic and environmental conditions and health status has been well documented in the literature, it is unknown whether parents of children attending rural ECCD centres, share this understanding. Children have the right to a healthy environment. Many children in rural Eastern Cape live in environments that present challenges in regards to water and sanitation, food security and safety. ECCD centres are the daily environment for the attending pre-school children and have a role to play in promoting child health. In order to develop effective, sustainable health promotion initiatives in ECCD centres a baseline recording was needed of the parental understanding of health, their children’s health needs and perceived solutions. Study Design: This study was an exploratory study, which used qualitative research methods to describe the parents’ perceptions of health and health needs of their children in ECCD centres in Amathole District, South Africa. Data Collection: Focus group discussions were the data collection method used to record the parental perceptions of health and child health needs. Because there was limited parental involvement in the ECCD centres, it was hoped that the focus groups would be a suitable method to generate more community involvement. Four focus groups were conducted using a semi-structured. The researcher facilitated the focus group discussions with the assistance of an isiXhosa speaking research assistant. The voice recordings of the discussions were professionally translated and transcribed for analysis. Analysis of Results: Content analysis of the transcriptions revealed a thick description of parental perceptions of health and child health needs. Participants saw health in holistic terms and identified a complex inter-relationship of various social determinants of health, consistent with Dahlgren and Whitehead's determinants of health model. Parents were aware of the absence of many of these determinants of health and the challenges to child health that this brought. The child health needs perceived by parents were related to nutrition, hygiene, social interaction, safety and protection from disease. Five recurring themes emerged as a result of this study, including individual lifestyle factors, social interaction, environmental challenges to health, safety and lastly poverty. The ECCD centres were considered a resource for child health and suggestions were given as to how to strengthen the ECCD centres' role in further promoting health. Conclusion: The participants' broad definition of health and depth of understanding regarding the determinants of health, allows for a range of stakeholders to be involved in the promotion of health in the ECCD centres. The majority of the perceived challenges to health existed in the living conditions of the children and families. The Health Promoting Schools (HPS) framework could enhance the current work of the Eco-Schools Programme in the ECCD centres.

Orientador: Fabio Luiz Mialhe / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-26T11:32:04Z (GMT). No. of bitstreams: 1 Paula_JaniceSimpsonde_D.pdf: 2936736 bytes, checksum: b902ec93fa51db820dff8577e0662b77 (MD5) Previous issue date: 2015 / Resumo: O objetivo geral dessa Tese foi avaliar os determinantes sociais da saúde (DSS) associados à saúde bucal, ao rendimento escolar e a qualidade de vida em crianças e adolescentes, além de testar as propriedades psicométricas longitudinais de questionários de Qualidade de Vida Relacionada à Saúde Bucal (QVRSB) e comparar um questionário genérico de qualidade de vida com outro de QVRSB. Para isso, foram usadas duas amostras: uma composta por crianças de 8 a 10 anos, participantes do Programa Sempre Sorrindo (PSS), no município de Piracicaba, São Paulo, e outra composta por escolares de 12 anos provenientes de escolas públicas e privadas do município de Juiz de Fora, Minas Gerais. Foram coletados dados referentes às condições clínicas e aplicados questionários para avaliação da qualidade de vida (Child Perception Questionnaire ¿ CPQ8-10 e CPQ11-14 e AUQUEI ¿ Autoquestionnaire Qualité de Vie Enfant Image), bem como do nível socioeconômico, do ambiente familiar e do rendimento escolar das crianças. Os resultados demonstraram que os DSS apresentaram associações com cárie dentária e que, em particular, os aspectos socioeconômicos possuíram maior associação com a experiência de cárie, quando comparados com variáveis relacionadas ao ambiente familiar. Observou-se, ainda, que tanto aspectos socioeconômicos, do ambiente familiar e a presença de lesões de cárie, mesmo que tratadas, foram indicadores de risco para o pobre rendimento escolar, e a experiência de cárie foi um importante preditor para mudanças na QVRSB de adolescentes ao longo do tempo. Sobre a responsividade dos instrumentos de QVRSB, verificou-se que o questionário CPQ11-14 apresentou-se responsivo às mudanças longitudinais, avaliadas pelo critério de Longitudinal Construct Validity, mas com pequena alteração quando avaliada pela análise de effect size. Os resultados também demonstraram que o CPQ11-14 apresentou correlação com o instrumento genérico de qualidade de vida AUQUEI e que ambos apresentaram associações com variáveis clinicas e socioambientais. Por fim, verificou-se que o tratamento da cárie dentária impactou positivamente na melhora da QVRSB de escolares, e o CPQ8-10 apresentou boas propriedades psicométricas para avaliar estas mudanças ao longo do tempo. Conclui-se, a partir dos resultados dos estudos supracitados, que houve associações entre DSS e a cárie dentária, e que ambos estiveram associados a um pior rendimento escolar. Da mesma forma, verificou-se que a QVRSB esteve correlacionada à qualidade de vida nesta população. Quando os escolares foram avaliados longitudinalmente, constatou-se que a experiência de cárie foi um preditor importante para mudanças da QVRSB ao longo do tempo nesta população, mensurada pelos questionários Child Perception Questionnaire, que apresentaram boas propriedades psicométricas de responsividade às mudanças de qualidade de vida relacionada à saúde bucal. Dentro deste contexto, o acesso ao tratamento odontológico foi um importante fator para a melhoria da qualidade de vida relacionada à saúde bucal de escolares que vivem sob vulnerabilidade social / Abstract: The overall objective of this thesis was to evaluate the social determinants of health (SDH) associated with oral health, school performance and the quality of life in children and adolescents, as well as test the longitudinal psychometric properties of Oral Health realte Quality of Life (OHRQoL) questionnaires and compare a generic questionnaire of quality of life with other of OHRQoL. For this, two samples were used: one consisting of children 8-10 years participating in the Program Always Smiling (PSS), in Piracicaba, São Paulo, and another composed of schoolchildren of 12 years from public and private schools in the city Juiz de Fora, Minas Gerais. Data were collected regarding on clinical conditions and questionnaires to assess quality of life (Child Perception Questionnaire - CPQ8-10 and CPQ11-14 and AUQUEI - Autoquestionnaire Qualité de Vie Enfant Image) and socioeconomic status, home environment and school performance of schoolchildren. The results showed that the SDH were associated with dental caries and, in particular, the socioeconomic aspects contained higher association with caries experience compared to variables related to the home environment. It was observed also that both socioeconomic aspects of the home environment and the presence of caries lesions, even if treated, were risk factors for poor school performance, and caries experience was an important predictor of changes in QVRSB adolescents over time. On the responsiveness of OHRQoL instruments, it has been found that the questionnaire is presented CPQ11-14 responsive to longitudinal changes, as evaluated by Longitudinal Construct Validity, but with little change as determined by the effect size analysis. The results also showed that CPQ11-14 correlated with the generic instrument of quality of life AUQUEI and both were associated with clinical, social and environmental variables. Finally, it was found that treatment of dental caries has impacted positively on improving of OHRQoL, and had good psychometric properties of CPQ8-10 for measuring changes over time. In conclusion, from the results of the aforementioned studies, there were associations between SDH and tooth decay, and both were associated with poorer school performance. Likewise, it was found that the OHRQoL was correlated to quality of life in population. When the students were assessed longitudinally, it was found that caries experience was an important predictor of changes OHRQoL over time in this population, as measured by the Child Perception Questionnaire questionnaires, which showed good psychometric properties of responsiveness to quality of life changes related to oral health. Within this context, access to dental treatment was an important factor in improving the quality of life related to oral health of children living under social vulnerability / Doutorado / Odontologia em Saude Coletiva / Doutora em Odontologia

A discriminação étnico-racial é um evento estressor capaz de produzir múltiplos danos físicos e mentais. Apesar do crescente interesse científico mundial e de ser tema estratégico para a saúde coletiva, permanece pouco estudado no Brasil, especialmente quando comparado aos EUA, responsável por expressiva produção acadêmica nessa área. Acerca das comunidades remanescentes de quilombo, são ainda mais escassos os dados disponíveis na literatura sobre a sua situação de saúde, sendo nula a investigação abrangendo discriminação étnico-racial entre esses indivíduos. Buscando contribuir para essas questões, a presente pesquisa analisou as frequências de discriminação entre os adultos quilombolas do município de São Lourenço do Sul/RS, por intermédio da escala Experiences of Discrimination, além de verificar as condições sociodemográficas e de saúde dessa população, mensurados pelos questionários da Pesquisa Nacional de Saúde adaptados para esse trabalho. Foram realizadas 103 entrevistas, sendo a amostra composta por 55,3% de mulheres, 71,8% com idades entre 18 e 59 anos e 72,8% da raça/cor preta. A prevalência de discriminação étnico-racial percebida em algum momento da vida foi de 59,2%, resultado superior ao encontrado em outros estudos importantes acerca do tema no país. As frequências com que os entrevistados reportaram ter sofrido discriminação nos contextos cotidianos investigados variaram de 1,9% ao pedir crédito ou empréstimo bancário até 28,2% ao frequentar a escola. Os itens acerca de agravos em saúde revelaram alta (64,1%) frequência de doenças crônicas, sendo a hipertensão arterial sistêmica (45,6%) a doença mais prevalente. Foram baixos os índices de tabagismo e de uso abusivo de álcool. Os resultados desse estudo permitem concluir que a prevalência de discriminação racial nas comunidades remanescentes de quilombo do município de São Lourenço do Sul foi alta e o local no qual ela foi percebida com maior frequência foi o ambiente escolar. É de suma importância que se reconheça a existência da prática do racismo dentro da sociedade brasileira para que se sistematizem ações para transformar essa realidade. / The ethnic-racial discrimination is a stressor event related to multiple physical and mental damages. However, despite the growing scientific interest in a global scale, it remains little studied in Brazil, especially when compared to the USA, responsible for expressive academic production in this area. Concerning the remaining communities of quilombo, the data available in the literature about their health status is even scarcer, with no research covering ethnic-racial discrimination on these individuals. In order to analyze these questions, the present study investigated the frequencies of discrimination among quilombola adults in the city of São Lourenço do Sul / RS, through the scale “Experiences of Discrimination”, beside verifying the sociodemographic and health conditions of this population, measured by questionnaires of the National Health Survey adapted for this work. A total of 103 interviews were conducted, with 55.3% of women, 71.8% between 18 and 59 years old, and 72.8% of blacks. The prevalence of ethnic-racial discrimination perceived at some point in life was 59.2%, a result superior to that found in other important studies on this matter in the country. The frequencies with which respondents reported discrimination in the daily contexts of the questionnaire ranged from 1.9% when applying for credit or bank loan up to 28.2% when attending school. The items about health problems revealed a high (64.1%) frequency of chronic diseases, with systemic arterial hypertension (45.6%) being the most prevalent disease. The rates of smoking and alcohol abuse were low. The results of this study allow us to conclude that the prevalence of racial discrimination in the remaining communities of quilombo in the municipality of São Lourenço do Sul was high and the place where it was most frequently perceived was the school environment. It is extremely important to recognize the existence of the practice of racism within Brazilian society to systematize actions to change this reality.

Social determinants of health (SDOH) are often used to discuss health inequities and systemic barriers experienced by minority populations. In the United States, the intersection of SDOH leaves these populations vulnerable to negative health outcomes. Missing from the SDOH discourse are the underlying historical causes for these disparities. Medical-Legal Partnerships (MLPs) have undertaken the role of educating the health and human services (HHS) workforce on interdisciplinary collaboration, cultural competence, and the skills to recognize experiences of negative SDOH. However, current research does not explore the foundational impact of historical trauma, more specifically Post Traumatic Slave Syndrome (PTSS), on experiences of negative SDOH. This ethnography primarily uses the personal accounts of black female HHS workforce members and participant observation from within a MLP to examine how historical trauma acts as a foundation for understanding the complex interactions of SDOH. The SDOH discourse does not challenge the medical and legal institutions that contribute to how minority populations experience negative SDOH. As currently structured, MLPs unintentionally reproduce a pedagogical narrative that erases the lived experiences of SDOH by only focusing on individual factors and not systems. Black female HHS workforce members agree that historical context is missing (e.g. PTSS) from the SDOH discourse and contemporary experiences of racism and discrimination. Historical context would change how HHS workforce members advocate for their patients as well as engage in system-challenging praxis within the medical and legal institutions. This suggests the need to examine how American institutions exclude particular histories and reinforces a white supremacist and patriarchal narrative.

No description available.

While the concept of the community health worker (CHW) has existed since the mid-20th century, their function as a legitimate branch of the broader workforce in the United States has been tenuous. Their unique roles have the potential to reduce health disparities within marginalized communities, but stakeholder development of this position risks diminishing the crucial skills of these workers. Anthropological research on these workers has typically assessed them in the developing world, while public health research has focused primarily on their ability to impact specific health outcomes through quantitative studies. As a result of the limited and predominantly quantitative assessments of these workers, further research is needed to assess the lived realities of these workers at the grassroots level in the United States. The overarching aim of this project was to document the lived experience of CHWs in Indiana. Additionally, this project assessed their participation in advocacy and the impact of policy development on these workers. A collaborative approach was utilized in this project that embedded the researcher within a CHW organization while also amplifying the voice of the research partners. The project drew on the theoretical lenses of moral economy, deservingness, structural vulnerability, and the “regimes of care” and “politics of care.” The results demonstrate that CHWs face a variety of challenges within the professional workforce but have significant impacts within their communities. These workers emphasize empowerment through advocacy and building client self-sufficiency. Their participation in advocacy is split between impacts at the micro-, macro-, and professional-level. However, legislating the scope and responsibilities of this position by stakeholders unfamiliar with this model risks changing the foundation of the position itself. Steps to incorporate CHWs within the workforce must be collaborative and take into account their lived experience and input in order to allow them agency over the development of their position and to retain the most significant contributions. The contributions of this project are severalfold. First, this project advances theoretical debates within anthropology related to moral economy, regimes of care, politics of care while also addressing the legitimacy of CHWs as a complimentary member of the health care workforce. The findings also illustrate how the political economy of Indiana shapes the moral economy of care within which CHWs operate. Lastly, the project produced applied findings for CHWs, employers, and stakeholders to consider in further development of this position.