Health care planners and administrators
are giving increasing attention to community
health workers as members of established
health care teams. This chapter describes
the events that, over time, marked their
progressive inclusion in public and private
health initiatives. A true history of
community health workers would begin more
than 300 years ago when communities recognized
the advantages of assigning to selected
gifted community members the responsibility
of assisting other members in health-related
matters.[1]
However, references in the literature
about CHW activities are found mostly
after the mid-1960s. Few studies in the
1950s described grassroots self-help projects
and basic outreach and education initiatives
by indigenous workers.[2]
Facts and critical events marking the
evolution of those grassroots initiatives
into what is now the CHW workforce have
been grouped into four periods spanning
the years 1966-1972, 1973-1989, 1990-1998
and 1999-2006. The list assembled here
is not intended to be comprehensive but
only suggestive of significant steps in
the development of the CHW workforce.
Early Documentation
(1966-1972)
During this period, attempts to engage
CHWs in low-income communities were experimental
responses to the persistent problems of
the poor and were related more to antipoverty
strategies than to a specific model of
CHW intervention for health improvement.
Few early studies described CHW effectiveness
and its potential.
- The Federal Migrant Health Act of
1962 mandated outreach, but there was
no substantial activity involving indigenous
CHWs until the 1970s.[3]
Earlier farmworker CHW activity, funded
by the former U.S. Children's Bureau,
was documented in the 1950s in Florida.[4]
- The earliest documented use of CHWs
by the New York City Health Department
was in a 1960s tuberculosis program
involving "neighborhood health
aides."[5]
- Early Federal support of CHW activity
came from the Office of Economic Opportunity
(OEO) for antipoverty efforts such as
"Model Cities" and the "New
Careers for the Poor" under the
OEO Act of 1964. In these initiatives,
job creation was an important objective.[6]
Studies discussing this initiative were
published as early as 1964.[7]
- One of the CHW programs that emerged
from the antipoverty initiative was
the Community Health Representative
Program for Native American populations.
It originated under the OEO in 1968
and was gradually transferred to the
Indian Health Service between 1969 and
1972.[8]
- One of the first effectiveness studies
on CHWs, in which CHWs worked with public
health nurses and physicians to encourage
compliance with treatment of pediatric
respiratory infections, was published
in 1970.[9]
- Early university-based research on
CHWs was conducted at Tulane in the
late 1960s and early 1970s in partnership
with Planned Parenthood of Louisiana
and included an early systematic look
at factors important to successful employment
of CHWs.[10]
- Although the Medicare and Medicaid
Programs were introduced in this period
(1965-1968), no documentation was found
of any plan to incorporate CHWs into
these programs.
Utilization of
CHWs in Special Projects (1973-1989)
No major milestones characterize this
period, but there was a steady growth
of projects funded by short-term public
and private grants. The projects were
often linked to research and, therefore,
during this period, there was a substantial
increase in published studies (see Figure
6.1 in Chapter 6). The studies provided
scholarly documentation of CHW potential
in interventions aimed at health promotion
and access to health services.
- In 1978, a World Health Organization
(WHO) declaration concerning CHWs was
a symbolic milestone that probably stimulated
attention to this workforce in the public
health sector.[11]
- The "Resource Mothers" curriculum
was developed for the Virginia Task
Force on Infant Mortality during the
1980s[12]
and became one of the early CHW curricula
widely distributed nationally. Indiana
used the curriculum to train personnel
for the State's community health worker
program, which began in 1994 and focused
on maternal and child health.[13]
International Medical Services for Health
(INMED) developed prototype materials
for the Resource Mothers programs, renamed
the Resource Mothers project MotherNet
in 1994, and continued to
provide handbooks for lay home visitors,
implementation guidelines for public
and private agencies, and curricular
materials for training resource mothers.[14]
- In 1989, the Health Education Training
Centers (HETC) program was created to
serve primarily the U.S.-Mexico Border
region and areas of high immigrant populations.
The program has played an important
role in promoting the utilization of
CHWs in public health projects.
- University-based studies explored
the potential of "natural helpers"
in improving community conditions through
the use of existing social networks
for problem-solving and diffusion of
positive health-related behaviors.[15]
State and Federal
Initiatives (1990-1998)
During this period, standardized training
received greater recognition, and communication
increased among CHW initiatives across
categorical funding programs. Many bills
were introduced at the national and State
levels, but none passed.
- Arizona Health Start, in 1992, was
one of the first CHW programs to receive
ongoing appropriations from State general
revenue.[16]
- Training centers were opened at the
Community Health Education Center in
Boston in 1993[17]
and at the City College of San Francisco
in 1994.[18]
- In 1993, the New Mexico Community
Health Worker Association was founded
with the support of the University of
New Mexico and, in 1996, began annual
CHW training conferences under a 3-year
development grant from the Robert Wood
Johnson and Henry J. Kaiser Family Foundations.[19]
Additional associations and networks
are listed in Appendix H.
- In 1993, the National Advisory Committee
on Rural Health and Human Services recommended[20]
that "The Secretary should develop
initiatives to broaden access and innovation
in health care delivery by supporting
local programs that utilize indigenous
community workers and paraprofessionals
as essential members of community health
care delivery teams."[21]
- In 1993, the Centers for Disease Control
and Prevention (CDC) awarded a grant
for one of the first national conferences
on CHW programs and related community-based
public health activity: "Mobilizing
Resources for Practice, Policy and Research."[22]
- In 1994, the Pew Commission for the
Health Professions published a landmark
descriptive study about CHWs as integral
members of the health care workforce.
It was excerpted in a 1995 article in
the American Journal of Public Health.[23]
- The U.S. Department of Education supported
college education for CHWs through a
San Francisco program that offered a
Community Health Worker Certificate
at the City College of San Francisco.[24]
- Kentucky Homeplace was established
in 1994 with an annual State appropriation
to support "Family Health Care
Advisors" to serve 58 counties,
mainly rural areas in the Appalachian
region.[25]
- A 1997 report sponsored by the Annie
E. Casey Foundation described the potential
for employing CHWs in contracts with
Managed Care Organizations.[26]
- In 1998, the Western Arizona Area
Health Education Center, a HRSA-sponsored
program, began organizing annual national
CHW training conferences.[27]
These conferences became a focal point
for the Promotores de Salud,
a distinct CHW workforce devoted to
improving the health status of Latino
communities.
- The Health Resources and Services
Administration, Bureau of Primary Health
Care organized, in 1998, the first major
national outreach conference on CHW
activities to discuss milestones in
the field and future strategies across
categorical funding programs.[28]
- The Annie E. Casey Foundation sponsored
the National Community Health Advisor
Study, the first project aimed at drawing
a national profile of CHWs and their
work. The study was released in 1998.[29]
Public Policy Options
(1999-2006)
The first State legislation specifically
addressing the CHW workforce was passed
at the beginning of this period, and the
language describing CHWs as "integral
members of the health care delivery team,"
first found in the 1994 study by the Pew
Commission, became frequently used with
reference to CHWs. Scientific sessions
with this title appeared at the American
Public Health Association (APHA) Annual
Meetings of 2005 and 2006.
- In 1999, CHW training and certification
legislation was passed in Texas.[30]
This bill mandated pilot projects involving
CHWs in Medicaid managed care as well
as a feasibility study on CHW certification.
- The El Paso Community College (EPCC)
Community Health Worker Program began
in the fall of 2000 as a community-driven
project.[31]
- In 2000, the National Rural Health
Association issued public policy statements
supporting expanded roles for CHWs.[32]
Similar statements were issued in 2001
by the American Public Health Association[33]
and in 2003 by the American Association
of Diabetes Educators.[34]
- In 2000, the APHA New Professionals
interest group changed its name to Community
Health Worker Special Primary Interest
Group (CHW SPIG).
- In January 2001, a meeting of State
and Federal representatives convened
in San Antonio, Texas, to discuss policy
options for integrating CHWs into programs
such as Medicaid, Women Infants and
Children (WIC), Food Stamps and Head
Start.[35]
- In 2003, credentialing legislation
(HB95) was passed in Ohio.[36]
- Three States passed bills mandating
studies of the State CHW workforce;
they were released in New Mexico (2003),[37]
Virginia (2006),[38]
and Massachusetts (2005).[39]
- In 2003, the University of Arizona
(Project Jump Start), supported by the
U.S. Department of Education, Fund for
Improvement of Post Secondary Education
(FIPSE), began the development of a
standardized CHW educational program.[40]
A follow-up project, the CHW National
Education Collaborative, was funded
by FIPSE in 2004.[41]
- The Institute of Medicine's 2003 report
on reducing health disparities made
recommendations regarding CHW roles.[42]
- A major study in 2003 by Brandeis
University recommended a central CHW
role in demonstration projects to address
disparities in cancer prevention and
treatment.[43]
The study led to the funding of six
demonstration sites for cancer Patient
Navigator services to minority Medicare
recipients.[44]
- The Federal Office of Minority Health
and the Agency for Healthcare Research
and Quality discussed the CHW role in
culturally sensitive interventions in
their 2004 research agenda on cultural
competence.[45]
- In June 2005, a Patient Navigator
bill was signed into law as the first
major CHW legislation adopted at the
Federal level.[46]
- In 2006, the Office of Management
and Budget solicited public comment
on changes to be considered for the
existing Standard Occupational Classification
system that may include "community
health worker" as an occupation.
The revision will be completed by the
end of 2008.[47]
Comments were submitted by the public
recommending the creation of a new code
for community health workers as a distinct
occupation.[48]
- A 2-year grant from the Robert Wood
Johnson Foundation to the Georgetown
University Law Center to create a national
network of CHWs began on August 1, 2006.
[1]
Rosenthal EL, Wiggins N, Brownstein JN
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[19] About Us [Internet].
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[30] HB 1864, which
became effective on 9/1/99, created the
Promotora Program Development Committee
(PPDC). Specifically, it stated: “The
purpose of this article is to establish
a temporary committee that will study
certain issues related to the development
of outreach and education programs for
promotoras or community health
workers and that will advise the Texas
Department of Health, the governor, and
the legislature regarding its findings.”
[31] Instructional Programs
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2005 [cited 2006 Nov 03]. Available from
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by the National Rural Health Association-November
2000 [Internet]. Kansas City (MO): National
Rural Health Association (NRHA); 2000
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24, 2001. Am J Public Health 2002; 92
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D, Broussard B et al. Position Statement
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[35] Sustainability
conference [Internet]. San Antonio (TX):
Family Health Foundation; 2001 [cited
2006 Nov 01]. Available from http://www.famhealth.org/new_page_3.htm.
[36] HB95 (125th General
Assembly); under this act, the Board of
Nursing was given the authority to develop
and implement a certification program
for community health workers and began
issuing certificates in February, 2005.
[37] New Mexico Department
of Health. Senate Joint Memorial 076 Report
on the Development of a Community Health
Advocacy Program in New Mexico. Santa
Fe (NM): Department of Health, November
24, 2003.
[38] Virginia Center
for Health Outreach. Final Report on the
Status, Impact, and Utilization of Community
Health Workers. Richmond (VA): James Madison
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[39] MDPH (2005).
[40] Proulx DE, Collier
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[41] Welcome [Internet].
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[42] Finding 5-2 and
Recommendation 5-10; Smedley BD, Stith
AY, Nelson AR, editors. Unequal Treatment:
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in Health Care. Washington (DC): Institute
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[43] Cancer Prevention
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and Racial Minorities. Baltimore (MD):
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[45]Report: Setting
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[46] HR 1812 Patient
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[47] Office of Management
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for 2010; Notice. Fed Regist 2006; 71
(94).
[48] SkillWorks, The
Boston Community Health Worker Initiative,
Full Partnership - August 17, 2006 Minutes
[Internet]. Boston (MA): Boston Community
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[updated 2006 Apr 17/cited 2006 Nov 02].
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