Chapter 8. The CHW Workforce in Selected States

This chapter describes community health workers' activities in Arizona, Massachusetts, New York, and Texas. These regional workforce profiles were assembled with data gathered from published and unpublished studies and reports, special tabulations of the CHW National Employer Inventory (CHW/NEI), and 48 unstructured interviews with employers and CHWs, elsewhere in the study referred to as the CHW National Workforce Study Interviews (CHW/NWSI). The results of the interviews from the larger States of New York and Texas were compared to the findings from the CHW/NEI and were found to reinforce those findings. The Inventory reponses from the smaller States of Arizona and Massachusetts were often too few to allow meaningful comparison.

The Population of the Selected States^[1]

In 2004, Texas and Arizona had higher percentages of Hispanics in their populations (35 and 28 percent, respectively) than did New York (16.1 percent), Massachusetts (7.7 percent), or the Nation (14.2 percent). In New York, the proportion of Blacks/African-Americans (14.7 percent) was greater than that in each of the other three States (3.0 percent in Arizona, 5.6 percent in Massachusetts, and 10.9 percent in Texas) and in the U.S. (12.0 percent). The population of Arizona had the largest percent of American Indian/Alaska Natives (4.2 percent) and Massachusetts the smallest (0.1 percent). Non-Hispanic Whites were half of the population of Texas, 80 percent of the population of Massachusetts, and 61 percent of the populations of New York and Arizona. Median household income was highest and above the U.S. value ($44,684) in Massachusetts ($55,658) and New York ($47,349); lowest, and below the national average, in Arizona ($41,995) and Texas ($41,759). The proportion of individuals without health insurance^[2] was 29 percent in Texas, 21 percent in Arizona, 13.7 percent in New York, and 10.3 percent in Massachusetts. In 2004, 14.5 percent of the country's population was uninsured.

CHW Demographics

The demographic characteristics of community health workers usually mirrored those of the communities they served. This finding was to be expected given the nature of their occupation and the fact that some employers required that they actually live in the communities they assisted, sharing language, culture, and socioeconomic status with the residents.^[3] In Arizona, CHWs were primarily American Indians/Alaska Natives, most of them tribal Community Health Representatives (CHRs), and Hispanics, mostly engaged in U.S.-Mexico Border or farmworker programs.^[4] In Massachusetts, they were mostly White (80 percent).^[5] In New York, 37 percent of CHW personnel were Black/African-American, 35 percent Non-Hispanic White, and one-fourth (25 percent) were Hispanic/Latino(a). In Texas, the CHW workforce was 68 percent Hispanic/Latino(a), 18.5 percent Non-Hispanic White, and 10.7 percent Black/African-American.^[6] A similar predominance of Hispanics/Latinos (77 percent) was found among the State-certified CHWs in Texas,^[7] more than twice the proportion of Hispanics/Latinos in the State population (35 percent), a result of the pressing health issues among underserved Latinos and of the cultural acceptance of the role of promotor(a).^[8]

In the selected States, as in the Nation, CHWs were mostly female between the ages of 30 and 50.^[9] Again, the predominance of women in this workforce was partly due to the focus of many programs on underserved children and their mothers^[10] as well as to clients' greater acceptance of female caregivers in their homes.^[11] Exceptions were found in certain programs such as Arizona nutrition programs,^[12] or fatherhood, HIV case management, and some youth programs^[13] in New York, which maintained a predominance of male workers.

Socioeconomic Characteristics of the CHWs

Most CHWs in Arizona had a high school diploma,^[14] and it was a requirement for CHRs in the Indian Health Service (IHS) program who were asked to be community health promoters, educators, and, when needed, health paraprofessionals.^[15] CHRs received wages comparable to those of an entry-level health aide at the county health department (less than $10 per hour)^[16] with incentives ranging from full fringe benefits to flexible work hours and reimbursement for training and education.^[17]

In Massachusetts, the CHW/NEI confirmed the finding, from an earlier survey,^[18] that the majority of CHWs had some college training, a higher level of education than the national average. Only 4 percent did not have the equivalent of a high school diploma.^[19] Most CHW supervisors had a college degree (88 percent).^[20] Organizations operating in the Boston metropolitan area and in unionized shops (i.e. hospital systems) paid the highest wages.^[21] The Massachusetts State Department of Public Health has been the main funding source of programs employing CHWs, a unique feature of that State. In large organizations, the outreach workers experienced some wage parity issues, and due to the definitional difficulties of the CHW occupation, they had to be classified by human resource departments in similar but not always comparable occupations that required fewer skills and paid lower wages.^[22]

Some employers interviewed in New York expressed preference for a college education (either associate or bachelor's level) but indicated flexibility in those requirements when the candidate had substantial community involvement and work experience.^[23] In the CHW/NEI, 30 percent of CHWs working in New York had a college degree, 22 percent had some college education, and 22 percent had a GED or a high school diploma.

In New York, the models of care delivery determined CHW wages. In hospitals, wages were based on pay equity scales for similar workers in the institutions.^[24] In municipal agencies, CHWs were provided with salaries and benefits commensurate to the county, city, or town pay scales.^[25] Providers with a unionized workforce were subject to union pay scales. Programs with appealing union or municipal benefit packages were able to attract workers from other programs without offering competitive wages.^[26] New York employers responding to the CHW/NEI indicated that 21 percent of new hires earned between $9 and $11 per hour and 35 percent between $11 and $13 per hour. The majority of experienced CHWs (62 percent) earned at least $15 per hour. A 1994 study reported that, in the New York metropolitan area, annual salaries for CHWs were between $18,000 and $25,000.^[27]

The educational attainment of Texas CHWs was lower than the national average. Graduation from high school or a GED was the highest level of education for 43 percent of CHWs. One-fourth of this workforce (24 percent) had obtained a 4-year degree. Of the CHWs certified by the Texas Department of State Health Services, only 8 percent had not graduated from high school, 40 percent had a high school diploma or a GED, and 21 percent had obtained a 4-year degree or higher.^[28] Newly hired CHWs in Texas were paid less than the U.S. average. The majority (66 percent) of them earned less than $11 per hour (13 percent earned less than $7 per hour) and only 9 percent earned $15 or more. Of the more experienced CHWs, 43 percent received less than $11 per hour and about one-third (29 percent) were paid an hourly wage of $15 or more.^[29] Most employers reported providing employee benefits and few mentioned non-monetary rewards such as participation in agency decision-making.^[30] Twenty-two percent of Texas employers offered tuition assistance.

Institutional Framework

In Arizona and New York, there were no specific State directives or legislative actions naming community health workers. However, one categorical CHW program, Arizona Healthy Start, after several years of sporadic support, in 1999 received funding by State legislation with the requirement that program sites were to provide a graduated in-kind contribution to match State dollars.^[31]

Massachusetts, unique among all other States, funded public health care services at the regional, local, municipal, and community level through the Massachusetts Department of Public Health (MDPH). Also, the State facilitated the formation of a CHW network as well as investigation into the training, education, and certification of CHWs.^[32] In 1995, the MDPH convened an internal cross-departmental task force to better understand the current and potential impact of the CHW workforce on health care delivery.^[33] In 1997, the task force developed guidelines for organizations receiving funds to support CHW activities.

Following the guidelines, in 2000, with the support of a grant from the Health Resources and Services Administration (HRSA), the MDPH began a 3-year project to implement the recommended goals. In 2000, the Massachusetts Community Health Workers (MACHW) network was established and the MDPH, in collaboration with the MACHW, produced policy recommendations, a CHW definition, description of best practices, and operational measures for funded programs.^[34]

In March 2006, the Massachusetts Legislature passed a health care reform bill^[35] to provide access to quality, accountable, and affordable universal health care for the citizens of the Commonwealth, eliminate health disparities, increase the use of primary care, and reduce the use of emergency room services.^[36] The law mandated CHW representation on the Massachusetts Public Health Council and required the MDPH to convene a statewide advisory board including the Commissioner of Public Health or designee and representatives of the Office of Medicaid, the Department of Labor, the Massachusetts Community Health Worker Network (MACHW), the Outreach Worker Training Initiative (OTWI) of Central Massachusetts AHEC, the Community Partners' Health Access Network, the Massachusetts Public Health Association, the Massachusetts Center for Nursing, Blue Cross Blue Shield of Massachusetts, the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts League of Community Health Centers, and the MassHealth Technical Forum to develop recommendations for a sustainable CHW program involving public and private partnerships.^[37]

Another State legislation that influenced some aspects of CHW employment in Massachusetts was the implementation of a 2001 emergency room interpreter law requiring all acute care hospitals and psychiatric inpatient hospitals to provide translator services, refundable by the State, without charge to patients.^[38] Fifty of the 80 hospitals in the State addressed the requirement.^[39]

In 1999, Texas was the first State to adopt substantive legislation directly affecting the utilization of CHWs.^[40] House Bill 1864, enacted by the 76th Texas Legislature, directed the Texas Department of Health (TDH)^[41] to design education programs for promotoras^[42] or community health workers. Two years later, the Promotora Program Development Committee (PPDC) recommended a system of credentialing based on the eight areas of "core competencies" identified in the 1998 National Community Health Advisor Study (NCHAS) sponsored by the Annie E. Casey Foundation.^[43] In 2001, Senate Bill 751^[44] directed the implementation of a promotor(a) or community health worker (CHW) training and certification program. The program has been voluntary for CHWs who do not receive compensation for their services and mandatory for paid CHWs. Also, the Bill required health and human services agencies to use certified CHWs/promotores(as) in performing health outreach and education programs for recipients of medical assistance under Chapter 32 of the Human Resources Code. For the first time, directives for Medicaid claims' administration and primary care case management services included the requirement of using certified CHWs in outreach and education activities.^[45]

Models of Care

The following State examples have been chosen as illustrations of the five models of care described in Chapter 3.

Members of care delivery teams

HIV programs in New York State used a comprehensive case management strategy employing a team approach that included a case manager, case management technician, and community health worker for follow-up visits to clients at their homes and for escorting them, when necessary, to access needed care.^[46]

CHRISTUS Spohn Health Care Hospital System in Corpus Christi, Texas, has assigned CHWs to emergency departments, primary care centers, and hospital floors. The CHWs in the emergency department teamed with clinical staff and followed patients from the emergency department through admission after discharge and visits with primary care physicians to ensure continuity of care. The emergency department found the program beneficial and requested its expansion.^[47] Hospital floor CHWs acted as resident patient advocates linking patients to appropriate problem solvers. The workers based in the primary care center spent part of each day taking vital signs but focused mainly on medication compliance.^[48]

Navigator

The African Services Committee in New York City used indigenous outreach workers to facilitate legal and immigration counseling, culturally and linguistically appropriate health care, linkages to food pantries, access to housing, and employment opportunities for a largely immigrant and refugee community.^[49]

Gateway to Care, a collaborative of 170 safety net health care systems and other organizations serving 1.09 million uninsured and underinsured individuals in Houston, Texas, employed community health workers as "Navigators" to establish cultural linkages between communities and health care providers and to facilitate outreach, eligibility determination, health promotion, referral, patient advocacy, and service coordination.^[50] Goals set for the CHW navigators included encouraging the utilization of primary and preventive care, improving patient-provider communication, and reducing inappropriate emergency room visits. Gateway was selected for a State-sponsored demonstration of navigator services to Medicaid recipients.^[51]

Screening and education provider

In Arizona, the Mariposa Community Health Center (MCHC) -- the largest provider of medical, dental, public health, and social services in the rural and low-income Santa Cruz County -- used a large group of CHWs (64 in 2004) for outreach programs aimed at informing communities of health care options and encouraging enrollment into available services. MCHC was designated in 2002 by the U.S. Department of Health and Human Services, Office on Women's Health, as a Community Center of Excellence in Women's Health.^[52]

CHW education and screening services were utilized by a dozen sites of the statewide perinatal health promotion program, Arizona Health Start, supported by annual State government appropriations.^[53]

Outreach/enrolling/informing agent

The Boston HIV Adolescent Provider and Peer Education Network (HAPPENS), housed at Children's Hospital in Boston, addressed case finding, case management, and outreach to adolescents between the ages of 12 and 20 who were lost to the health care system and were diagnosed with HIV. The program combined the CHW outreach role with the role of patient liaison to the clinical staff.^[54] The HealthFirst Family Care Center, a Federally Qualified Health Center (FQHC) in Fall River, Massachusetts, employed CHWs to promote the health center and its programs through attendance at community events such as health fairs and educational presentations.^[55]

Organizer

North End Outreach Network (NEON) of Springfield, Massachusetts, has been operating as a social service community advocacy organization with the Baystate Medical Center, also of Springfield, acting as its fiscal agent. NEON used a multi-intervention approach aimed at reaching every household in its geographic area. Seven community health advocates (CHAs) were responsible for door-to-door outreach in one of 10 geographic zones encompassing the targeted area. Also, CHAs were assigned to neighborhood schools where they worked with students and families in projects especially designed for young people, such as a digital storytelling program for hand-held devices with stories and music created by local youth. NEON maintained a database on the area's residents and addressed, when needed, other issues indirectly related to the health status of the residents such as education, literacy, employment, housing, and public safety.^[56]

The role of CHWs (promotores) in the Texas colonias^[57] has been that of connecting residents to health services available outside the community. This assistance has been critical since these communities lack not only health services but also some basic living necessities. Promotores developed environmental health community education seminars and facilitated outside groups in conducting research to bring some relief to the many high-risk health conditions of colonias' residents.^[58]

CHW Activities

Table 8.1 compares the percentages of New York and Texas employers reporting each type of service provided by their CHW employees relative to the percentage of employers nationwide reporting the same services. The regional differences were minor and suggest that CHWs have been engaged throughout the United States with similar frequency in the same group of health care activities. Emerging duties for CHWs, as reported during State interviews, included providing assistance in organizing and managing care, in investigating clients' concerns, and articulating clients' needs.^[59]

The special populations served are shown in Figure 8.1, the health issues addressed by CHWs are in Table 8.2, and the skills required by employers are in Figure 8.2. The State profiles closely shadowed the Nation except for bilingualism which, predictably, was more frequently selected by Texas respondents as an important skill. The description of education requirements, the importance of cultural competence, recruitment methods, training, education, certification, and funding streams presented in Chapters 3 and 5 apply to these selected States as well. Interesting regional examples are included in Appendix G.

Table 8.1 Services Provided by CHWs in New York, Texas, and the United States by Percent of Respondents

Source: CHW National Employer Inventory (CHW/NEI) (2006); multiple responses permitted.

[D]

Source: CHW/NEI (2006).

Table 8.2 Health Problems Addressed by Programs, Percent of Respondents

Source: CHW/NEI (2006); multiple responses permitted.

[D]

Source: CHW/NEI (2006).

Selected Examples of HRSA-supported Programs in Arizona, Massachusetts, New York and Texas.

• Border VISION Fronteriza (BVF) was funded by HRSA from 1995 to 1998 through the University of Arizona Rural Health Office to conduct a U.S.-Mexico Border Health Collaborative Outreach Demonstration Initiative.^[60] It produced a model training curriculum for promotores or CHWs in a "Promotora Academy." The services of this academy remained with the Health Education Training Centers Alliance of Texas (HETCAT), with some components absorbed in other educational programs including the Community Health Advocate Program at El Paso Community College. The emphasis of a second phase of BVF has been on improving access to health care for low-income children by expanding enrollment in publicly funded insurance programs.^[61]

• Under the Western (Arizona) Area Health Education Center (WAHEC), beginning in March 2001, the Community Access Program of Arizona (CAPAZ) project utilized CHWs to support Yuma County's medical "safety net."^[62] CHWs assisted in recruiting people in public health insurance programs, providing information about available medical and social services, and making referrals.

• The New England AIDS Education and Training Center (NEAETC) at the University of Massachusetts was established in 1988 as one of 11 regional HIV education centers funded through the Ryan White Act, Part F, across the United States.^[63] The center offered training programs for health care providers in the six New England States including training opportunities for CHWs.^[64]

• HRSA supported community health centers in New York through Title III (330) funding; these included the Charles B. Wang Community Health Center, a Federally Qualified Community Health Center that began in 1971 as the Chinatown Clinic. The Center had extensive outreach, education, and navigator services provided by 140 outreach workers to the Asian community in Manhattan and Queens. The frontline health care workers were not called community health workers but had titles indicating similar roles, such as patient service representatives, social work assistants, care managers, and lay health educators.^[65]

• The Buffalo Prenatal-Perinatal Network was the beneficiary of a $1.5 million grant from HRSA that ended in 2002.^[66] The grant permitted the expansion of the Network's home visiting program, enabled recruitment of specific kinds of needed workers, and provided funding for consortia, forums, and conferences to educate providers and clients about CHWs.^[67]

[1] U.S. Census Bureau, 2004 American Community Survey Data Profile Highlights.

[2] Behavioral Risk Factor Surveillance System (BRFSS).  Atlanta, Georgia:  U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.  In the BRFSS, respondents were asked "Do you have any kind of health care coverage?"

[3] Walker MH. Building Bridges: Community Health Outreach Worker Programs. New York (NY): United Hospital Fund of New York; 1994.

[4] Staten LK, Gregory-Mercado KY, Ranger-Moore J et al. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. J Womens Health (Larchmt) 2004; 13 (5):547-56; Buller D, Buller MK, Larkey L et al. Implementing a 5-a-day peer health educator program for public sector labor and trades employees. Health Educ Behav 2000; 27 (2):232-40.

[5] Massachusetts Department of Public Health. Community Health Workers: Essential to Improving Health in Massachusetts, Findings from the Massachusetts Community Health Worker Survey. Boston (MA): Division of Primary Care and Health Access, Bureau of Family and Community Health, Center for Community Health, March 2005. Note: Race and ethnicity were reported separately in this report. In the CHW/NEI, race/ethnicity were reported as Non-Hispanic White or Hispanic/Latino(a).

[6] CHW National Employer Inventory (CHW/NEI) (2006).

[7] Community Health Workers in Texas Demographic Data. Austin (TX): Texas Department of State Health Services, March 2006; reflects 545 certified CHWs in Texas.

[8] Despite subtle differences, the terms promotores and promotoras, defined in Chapter 1, have been used interchangeably with the term community health worker in Mexico, Latin America, and Latino communities in the U.S.

[9] Staten LK et al. (2004); Ingram M, Staten L, Cohen SJ et al. The use of the retrospective pre-test method to measure skills acquisition among community health workers. Internet Journal of Public Health Education 2004; B6-1-15; United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Mariposa Community Health Center of Excellence in Women's Health Model, Santa Cruz County, Arizona. El Paso, TX: United States-Mexico Border Health Commission, 2004.

[10] CHW National Workforce Study Interviews (CHW/NWSI) (2006).

[11] Ibid.

[12] Staten LK et al. (2004); Buller D et al. (2000).

[13] CHW/NWSI (2006).

[14] Buller D et al. (2000); Ingram M et al. (2004).

[15] Meister JS, Moya EM, Rosenthal EL et al. Community Health Worker Evaluation Tool Kit. El Paso (TX): Funded by The Annie E. Casey Foundation and produced by The University of Arizona Rural Health Office and College of Public Health 2000.

[16] Meister JS, Warrick LH, de Zapien JG et al. Using lay health workers: case study of a community-based prenatal intervention. J Community Health 1992; 17 (1):37-51; Brownstein JN, Cheal N, Ackermann SP et al. Breast and cervical cancer screening in minority populations: a model for using lay health educators. J Cancer Educ 1992; 7 (4):321-6.

[17] CHW/NWSI (2006).

[18] Massachusetts Department of Public Health. Community Health Workers: Essential to Improving Health in Massachusetts, Findings from the Massachusetts Community Health Worker Survey. Boston (MA): Division of Primary Care and Health Access, Bureau of Family and Community Health, Center for Community Health, March 2005.

[19] Ibid.

[20] Ibid.

[21] CHW/NWSI (2006).

[22] Ibid.

[23] Ibid.

[24] Ibid.

[25] Ibid.

[26] Ibid.

[27] Walker MH (1994).

[28] TDSHS (2006); reflects 545 certified CHWs in Texas.

[29] CHW/NEI (2006).

[30] CHW/NWSI (2006).

[31] Bridge M, Iden S, Cunniff C et al. Improving access to and utilization of genetic services in Arizona's Hispanic population. Community Genetics 1998; 1 (3):166-8; Meister JS et al. (2000).

[32] CHW/NWSI (2006).

[33] MDPH (2005).

[34] Ibid.

[35] Chapter 58 of the Acts of 2006, called an Act Providing Access to Affordable Quality Accountable Health Care.

[36] An Act Providing Access to Affordable, Quality, Accountable Health Care, House Bill No. 4850, Section 110 [Internet]. Boston (MA): Massachusetts State Government; 2006 [cited 2006 Aug 11]. Available from http://www.mass.gov/legis/bills/house/ht04/ht04850.htm.

[37] Ibid.

[38] Youdelman M, Perkins J. Providing language Interpretation Services In Health Care Settings: Examples From the Field. New York (NY): The Commonwealth Fund, May 2002.

[39] Ibid.

[40] Family Care Coordination [Internet]. Indianapolis (IN): Indiana State Department of Health; 2006 [updated 2001 Oct 02/cited 2006 Jun 19]. Available from http://www.state.in.us/isdh/programs/mch/fcc.htm. Note: Indiana implemented "Family Care Coordination" services for pregnant women and infants receiving Medicaid under provisions of an Omnibus Reconciliation Act of 1989 and of 1990, which includes home visiting for pregnant women and/or children, although the original legislation did not provide for CHWs as a class of workers in home visiting. In addition, a 1998 Bill in Maryland (House Bill 650) was aimed at requiring HMOs to employ CHWs to educate Medicaid recipients.

[41] Relevant functions of TDH became part of the Texas Department of State Health Services (TDSHS) in 2004.

[42] The term common in Hispanic communities is used in Texas and other U.S./Mexico Border States as a synonym for CHWs despite subtle differences in meaning -- in Spanish the term promotores(as) emphasizes "health promotion" involving activities not always strictly defined as health services.

[43] Rosenthal EL, Wiggins N, Brownstein JN et al. The Final Report of the National Community Health Advisor Study. Tucson (AZ): University of Arizona, 1998.

[44] Enacted by the 77th Texas Legislature.

[45] Rush CH: Current issues in the field [Internet]. San Antonio (TX): Family Health Foundation and South Texas Health Research Center; 2004 [updated 2004 Dec 05 /cited 2006 Nov 03]. Available from http://www.family-health-fdn.org/CHWResources/issues.htm.

[46] CHW/NWSI (2006).

[47] Rush CH. Conversation with: Bert Ramos (Director, CHRISTUS Spohn Family Health Center- Westside). 2006 May 01.

[48] Ramos B. Best Practice Entry Form: Community Health Workers in a Primary Care Setting. Corpus Christi (TX): CHRISTUS Spohn Hospital Corpus Christi-Memorial, Nueces County Hospital District, March 2005.

[49] CHW/NWSI (2006).

[50] Gateway to Care Opening Doors to Healthcare [Internet]. Houston (TX): Gateway to Care; 2000 [updated 2006 Oct 19/cited 2006 Nov 03]. Available from http://www.gatewaytocare.org/.

[51] Rush CH. Conversation with: Kimberly Camp. 2005 October.

[52] United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Mariposa Community Health Center of Excellence in Women's Health Model, Santa Cruz County, Arizona. El Paso (TX): United States-Mexico Border Health Commission, 2004.

[53] Meister JS et al. (2000); Office of Women's and Children's Health - Health Start [Internet]. Phoenix (AZ): Arizona Department of Health Services, Division of Public Health Services; 2006 [updated 2006 Sep 13/cited 2006 Oct 9]. Available from http://www.azdhs.gov/phs/owch/healthstart.htm.

[54] CHW/NWSI (2006).

[55] Ibid.

[56] Ibid.

[57] The term colonia and its plural, colonias, mean, in Spanish, community(ies) or neighborhood(s). In the U.S., these terms are being used to describe low-income or economically distressed residential areas along the United States/Mexico Border and in other regions of the country that may lack some of the most basic living necessities, such as potable water and sewer systems, electricity, paved roads, and safe and sanitary housing.

[58] May ML, Bowman GJ, Ramos KS et al. Embracing the local: enriching scientific research, education, and outreach on the Texas-Mexico Border through a participatory action research partnership. Environ Health Perspect 2003; 111 (13):1571-6.

[59] CHW/NWSI (2006).

[60] Laws MA. Foundation approaches to U.S.-Mexico Border and binational health funding. Health Aff (Millwood) 2002; 21 (4):271-7; Southwest Border Health Research Center. An Overview: Health Care Coverage in Arizona. Tucson (AZ): The University of Arizona College of Public Health for The Arizona Health Care Cost Containment System, January 2002.

[61] United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Border Vision Fronteriza 2 New Mexico Model. El Paso (TX): United States-Mexico Border Health Commission, 2004.

[62] United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Community Access Program of Arizona (CAPAZ) and Entre Amigas (Between Friends) Model, Yuma County, Arizona. El Paso (TX): United States-Mexico Border Health Commission, 2004.

[63] About Us [Internet]. Boston (MA): The New England AIDS Education and Training Center (NEAETC); 2005 [cited 2006 Sep 01]. Available from http://www.neaetc.org/about/; CHW/NWSI (2006).

[64] CHW/NWSI (2006).

[65] Ibid.

[66] Ibid.

[67] Ibid.