Small Shifts, Big Impacts: Lessons From Co-Designing with Community Health Workers to Create Healthier Communities

By Sarah Primeau, MSW, MPH, Director, Program

Food is Medicine (FIM) and other nutrition interventions—like medically-tailored meals, groceries, and produce prescriptions—have moved from pilot to policy in under a decade. In Massachusetts where I’m based, MassHealth (the Medicaid program here), private payers, and health systems are increasingly investing in FIM as evidence-based programs for managing chronic conditions. But these programs often fall short for under-resourced communities, especially communities of color, which frequently face limited access, lower participation rates, and persistent concerns about the  cultural relevance of the food provided. 

Community health workers (CHWs)—trusted, local leaders and caregivers—are rarely trained in, deployed to, leading, or designing FIM interventions and are often positioned as referral extenders, rather than clinical team members. The result is that those with relationships to make FIM efforts successful have no formal role inside them. But what if those closest to the health challenges communities are facing could design the solutions?  

With our partners at Biogen, and the Greater Boston Chinese Golden Age Center, I had the privilege of co-leading phase one of a project with a Boston-based academic medical institution that put CHWs at the center of designing a new approach to nutrition and FIM training and clinical integration. My job was to set the table so CHWs and community members could shape decisions about what is included in nutrition education, what CHW nutrition training looks like, and how culturally responsive nutrition support is integrated across community and clinical settings. 

We started by listening. Community members and CHWs told us that people don’t need more generic nutrition advice or pre-made meals. Instead, they need guidance that reflects the foods they actually eat, that celebrates their cultures, what they can afford, and the realities of daily life. While seemingly small shifts, decision points led by those who know the community best are actually critical to a more effective, more equitable effort, and a master class in how co-design actually works. 

That, to me, is the heart of co-design. The people closest to the challenge aren’t simply there to provide input. They hold expertise that changes what gets built. And across this first phase of the work, the impact of true co-design surfaced again and again. Four lessons, in particular, will shape how we move forward.

Lesson 1: Community co-design improved relevance and usability

We know from our prior work that community input strengthens program design, but this initiative reinforced the importance of involving community members throughout the entire development process. Community members, CHWs, and CBO staff shaped both the content and format of our nutrition education materials.

One example came from our work with the Chinese community. Rather than telling people to avoid a beloved cultural staple because it was high in sodium, we explored how to make a familiar recipe healthier – preserving the food and the culture while giving people more tools and choices. As one CHW so perfectly put it:

“It is not our responsibility to tell them what to eat and what not to eat. But we can show them what is in their food and help them make decisions and choices.”

That same principle showed up in the format of the materials, too. We wouldn’t have predicted that older adults would prefer short videos for nutrition education. But participants told us that social media video was a format they already used and trusted, so we incorporated it into the final materials. It was a small decision, but an important one. The takeaway: community voice shouldn’t just influence what we build; it should influence how we build and deliver it.

Lesson 2: CHWs belong at the start of curriculum design – not the end

Our CHW focus group and design session made clear that CHWs bring a kind of practical expertise that can’t be replicated from a curriculum or clinical perspective alone. Through real-world case scenarios, CHWs identified the knowledge, communication skills, and resource navigation tools they need to support people experiencing food insecurity and chronic disease. Their input directly shaped the four competencies, grounding the curriculum in the realities of CHW practice rather than an idealized clinical model.

Going forward, CHWs won’t simply be the people we train. They will remain co-designers of the training itself.

Lesson 3: Trust is the foundation of meaningful engagement

Our partnership with the Greater Boston Chinese Golden Age Center was critical. Their bilingual staff, established relationships, and credibility within the Chinese community strengthened recruitment and participation – but perhaps more importantly, they created the conditions for people to share honest feedback and shape the work. The partnership reminded us that meaningful engagement starts long before a project launches. 

As we expand into Haitian and Latinx communities in Boston and Lowell, we will prioritize strong CBO partnerships and invest time in building trust before asking communities to participate in development or implementation. We move at the speed of trust and can’t co-design with a community you haven’t taken the time to know.

Lesson 4: The next phase must address implementation, not just education

Nutrition knowledge alone does not overcome barriers to healthy eating. Our conversations with community members and CHWs made clear that cost, food access, time, transportation, and the availability of culturally appropriate foods all shape whether someone can act on nutrition guidance. That reinforced the importance of integrating food insecurity screening, resource navigation, and FIM connections into CHW training and not treating nutrition education as a standalone skill.

It also reinforced that lasting change requires action beyond the individual level. As this work moves forward, we will continue to elevate community and CHW voices in the policies and systems that shape food access and health, pairing community-informed education and implementation with advocacy efforts that uplift their expertise and advance more equitable access to culturally responsive nutrition and Food Is Medicine resources.

That is where this work goes next: from what CHWs know, to what they can help make possible. We will test how CHWs can connect nutrition education to actual food resources, clinical referrals, and community programs, and learn what it takes to make those connections work in practice.

In the first phase of this project, we saw again, as we often do in our work, that the lesson isn’t that we need bigger ideas. It was that when we create the conditions for community expertise to shape decisions early and often, the shifts may look small, but the downstream impact on people’s health and well-being is anything but.

Learn more about Sarah and follow her on LinkedIn. To learn more about our work in the region, contact Tigee Hill at thill@healthleadsusa.org