Navigating double burden: Community health workers in rural Dominican Republic living and working through the epidemiologic transition

The epidemiological transition postulates that over time, the burden of infectious disease declines and is replaced with non-communicable diseases (NCD). Community health workers (CHW) work on prevention and treatment of infectious and NCD in low-resource settings in the context of health transitions. We explored CHWs' experiences working through the epidemiologic transition in rural Dominican Republic and how the transition impacted their roles and communities. We conducted two semi-structured interviews each with eight CHWs. We analyzed interviews using narrative summaries and thematic coding. CHWs described themselves as change makers that drove health improvements, including child mortality reductions and advancements in social determinants of health. However, more than a transition from infectious disease to NCD, participants described a current double burden of both, and a resulting expansion of their roles and responsibilities. Increased workloads and poor remuneration, layered on top of gendered roles and expectations, were identified as threats to CHW sustainability, efficacy, and well-being. CHWs need additional support to continue their essential role strengthening the health profile of communities in transition.