Advancing Early Relational Health: How Community Health Workers Build Trusting Relationships with Families

“What do you actually need? How can I actually help?”

These are the questions Nai Pharn, a Community Health Worker (CHW) at UCSF Benioff’s Children’s Hospital Oakland, found herself asking while meeting for the first time with an overwhelmed mother about renewing her CalFresh benefits. When the mother began getting teary-eyed, Pharn paused and asked how she could truly be useful in that moment. The mother confided she was having trouble printing out some forms. Within minutes Pharn had printed out the forms for the mother, and then helped her fax her renewal request. So simple, yet so meaningful for this mom.

Though perhaps unique in its specifics, this interaction is typical of the CHWs who serve in UCSF Benioff’s Children’s Hospital Primary Care Clinic (UCSF BH Oakland). Known as Navigators, these CHWs meet with children and parents before or after their clinic visits as part of the Family Information and Navigation Desk (FIND) Program. Building on their relationships with families, navigators respectfully offer families information and support about food, housing, legal advice, family activities, and other social drivers of health. They seek to remove structural barriers that impede access to the resources that are critical to family stability and the alleviation of stress. By connecting families to the supports they need, families’ sense of certainty, security, and hope are strengthened, all of which are foundational in supporting early relational health, a term that captures the importance of positive and nurturing relationships that advance physical and mental health and development, social well-being, and resiliency in the early years of life. CHWs strive to honor and join with the families’ priorities, stay fully present in the relationship, and remain flexible and responsive. Most of all, they build trust with the families they serve, ensuring families understand that they are the experts in what resources they need and can use their expertise. These skills come easily to talented CHWs—so easily, in fact, that sometimes neither CHWs nor their advocates can articulate exactly how this trust-building happens.

So how do Navigators build these critical trusting relationships with families of multiple races, ethnicities, and social circumstances?

Racial and ethnic concordance. The Navigators are especially important to advancing equity and racial justice, given the long-standing racist institutional and structural barriers that block Black, Indigenous, Latinx, Asian, and immigrant families from accessing the housing, food, activities, and legal services that they need. Too often, well-intentioned health care providers reinforce paternalistic and racist power structures in their interactions with patients or when they give parenting advice. And often, the White dominant professional community may not appreciate how historical oppression, injustice, and system failures influence the learned, adaptive, and protective parenting practices passed down generationally. An early relational health approach advises health professionals to listen to parents; reflect on their own mindsets about parenting; reflect with parents on their heritage and history of their own parenting experience; celebrate a family’s strengths and capacities; and authentically model respectful, dignified, and caring relationships. These elements within the clinical relationship with families may be meaningful to parents, potentially transformative, and promote stability and growth for the infants and young children in their home. In this way, the clinician-family relationship also promotes early relational health.

Navigators play a crucial role in addressing these structural barriers by building trust and then helping families access the resources they want and  need. Crucially, Navigators almost always come from the communities they serve, which helps to create an authentic, trusting relationship. As Marina Franco comments, “Letting people know that I see them, I’ve grown up with them—it’s an instant connection.” Alejandra Plata, who was raised in Oakland, says that she relates to many of her families’ struggles, and often shares stories from her own childhood or adolescence. To Artanesha Jackson, who manages the FINDConnect program, this is absolutely key. “Our Navigators are successful because they come from the community,” she says. “They hold a space for the family that no-one else can.”

Sharing a language, culture, and even a neighborhood does more than create trusting bonds. It also helps to ensure that the screens and guidelines used in the medical setting are culturally appropriate and reflective of the community being served. For instance, while conducting a developmental screening in Arabic, Maoya Alqassari noticed that some children were “failing” certain developmental milestones simply because they had never seen the Cheerio referenced in the test. Alqassari alerted the attending pediatrician, who devised alternate ways to adapt  the testing in ways that account for culture and experience. Although modest about her contributions, Alqassari says, “I like [my families] to know that I’m looking out for them.”

Listening like your whole body is an ear. The second way the Navigators build trusting relationships with families is deceptively simple: they listen. In a busy pediatric clinic, Navigators take the time to introduce themselves, bond with families, and explain the FIND program—all elements essential to building a true relationship. Franco explains how when she asks a parent ‘Are you okay? How are you doing?’, she hears the relief in the parent’s voice. “They sort of give this little chuckle,” she recounts, “Like: Huh. Someone’s asking about me, about my health…” Pharn agrees, saying, “Just being physically there and listening and genuinely caring” counts for a lot.”

Families guide the conversation. The third element of building trusting relationships is a key pillar of anti-racist approaches to addressing social drivers of health: families must drive the interaction. The Navigators all spoke of being guided by families’ priorities. Alejandra Plata says, “I never assume a family is going through something, instead I ask.” The story shared at the opening of this blog post reflects Pharn’s willingness to slow down and let parents guide the interaction. Alqassari says she always asks, “What’s important to you, what do you want to prioritize?” Navigators understand that no one knows better than the parents what they or their family needs and let the parent lead.

Reflecting on the work. Finally, Navigators celebrate successes with families. Enrolling in a program, finding a new apartment, or signing a child up for art classes—all are occasions for celebration. Reflecting on this cheerleading, Franco says, “All that good energy and feedback is encouraging.” So often families are not encouraged by systems that judge them for their failures or based on implicit biases and/or racial stereotypes. Navigators deliberately try to counter these negative experiences and support families building their voice  and confidence.

The trust-building that Navigators do is not only helpful for connecting families to resources in an equitable and respectful way, but it also fosters family well-being, a sense of personal agency, hope, and pride. Alqassari recalls running into a former client on the street a few months after working together. Excitedly, the mother told Alqassari how she had found a new apartment and job. “You really helped me out,” the mother said. CHWs help families—in small and often dramatic, life-changing ways. With trust, heart, and knowledge of the community, CHWs are powerful aids in helping a family achieve their goals. These qualities, in turn, are key for building early relational health.

Navigators contribute to ERH by supporting family well-being and modeling healthy relationship-building and healing. They listen, stay fully present, ask questions, and share their own life experiences. Navigators also embody an ERH mindset through integrating ERH practices and principles into their standard work. For instance, Pharn helps run the Resiliency Clinic, a group focusing on the parent-child relationship, stress reduction and early relational health. Here, parents learn how to cultivate mindfulness, a ‘circle of security,’ and deep breathing, all of which helps them be more fully present with their child.

Navigators, in addition to carrying out more traditional tasks of administering the screening for social drivers of health and adversity, can do meaningful relational work that can redefine a clinical practice: they build a trusting bond with parents and staff which helps the parents communicate honestly about what they need. In this way, families feel heard, valued, and respected. Navigators call on their own personal relational health skills, their own nuanced social and emotional skills, along with cultural literacy and knowledge to be authentic and valued by families.

Every community child and family clinic needs such relational health ambassadors and champions to further the future well-being of all families. These community health workers are the essential team members for ensuring that family needs are understood and met and for advancing relational health and the well-being of communities, families, and children. 

Dayna Long (1)Dr. Dayna Long is a pediatrician with special interests in community health and engagement, and in promoting equity in health care. At UCSF Benioff Children’s Hospital Oakland, she completed a residency in pediatrics and a fellowship in infectious diseases. She has additional training in incorporating cultural humility into patient care.