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from published and unpublished studies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
Services
|
New York
(N=44) |
Texas
(N=91) |
U.S.
(N=596) |
Assisting
in gaining access to medical services
and programs |
90.9
|
81.3
|
84.4
|
Providing
culturally appropriate health promotion
and education |
81.8
|
87.9
|
81.7
|
Assisting
in gaining access to non-medical services/programs
|
77.3
|
68.1
|
71.6
|
Community
advocacy |
61.4
|
53.8
|
53.0
|
Social
support |
61.4
|
42.9
|
45.8
|
Case
management |
65.9
|
41.8
|
45.0
|
Risk
identification |
68.2
|
30.8
|
40.9
|
Building
individual capacity |
52.3
|
39.6
|
38.8
|
Providing
direct services |
34.1
|
35.2
|
37.4
|
Translation
|
38.6
|
49.5
|
35.6
|
Transportation
|
40.9
|
37.4
|
35.6
|
Building
community capacity |
25.0
|
40.7
|
34.9
|
Interpretation
|
34.1
|
44.0
|
33.6
|
Counseling
|
36.4
|
31.9
|
30.5
|
Mentoring
|
22.7
|
24.2
|
20.6
|
Cultural
mediation |
11.4
|
24.2
|
18.0
|
Patient
navigation |
22.7
|
15.4
|
17.8
|
Other
|
15.9
|
8.8
|
10.6
|
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
Health
Problem or Issue |
New York
(N=43) |
Texas
(N=88) |
U.S.
(N=587) |
Nutrition
|
55.8
|
52.3
|
50.3
|
Women's
health |
62.8
|
47.7
|
48.6
|
Pregnancy,
prenatal care |
55.8
|
33.0
|
43.4
|
Child
health |
53.5
|
42.0
|
42.9
|
HIV/AIDS
|
76.7
|
29.5
|
41.6
|
Diabetes
|
30.2
|
59.1
|
40.0
|
Infant
health |
55.8
|
34.1
|
40.0
|
Immunizations
|
53.5
|
38.6
|
39.0
|
Sexual
behavior |
48.8
|
37.5
|
35.9
|
Obesity
|
30.2
|
40.9
|
34.9
|
Family
planning |
53.5
|
33.0
|
33.7
|
High
blood pressure |
23.3
|
46.6
|
33.2
|
Breastfeeding
|
53.5
|
28.4
|
31.9
|
Tobacco
control |
44.2
|
22.7
|
31.3
|
Physical
activity |
20.9
|
33.0
|
30.0
|
Low
birth weight prevention, follow-up
|
48.8
|
18.2
|
29.8
|
Premature
birth prevention, follow-up |
51.2
|
22.7
|
29.1
|
Substance
abuse |
48.8
|
25.0
|
29.0
|
Cancer
|
16.3
|
34.1
|
28.3
|
Cardiovascular
disease |
18.6
|
38.6
|
27.3
|
Mental
health |
44.2
|
26.1
|
27.3
|
Heart
disease |
14.0
|
27.3
|
24.4
|
Men's
health |
18.6
|
20.5
|
23.0
|
Children
w/special health care needs |
39.5
|
22.7
|
22.8
|
Asthma
|
16.3
|
23.9
|
19.4
|
Violence
|
30.2
|
23.9
|
19.4
|
Lead
poisoning |
46.5
|
13.6
|
19.1
|
Other
|
20.9
|
29.5
|
18.7
|
Stroke
|
9.3
|
12.5
|
14.3
|
Injuries
|
14.0
|
10.2
|
11.8
|
Tuberculosis
|
18.6
|
13.6
|
11.4
|
Gay,
lesbian, bisexual, transgendered issues
|
9.3
|
8.0
|
11.1
|
Emergency
response |
11.6
|
11.4
|
10.6
|
Osteoporosis
|
7.0
|
8.0
|
8.5
|
Arthritis
|
2.3
|
6.8
|
8.2
|
Alzheimer's
disease, dementia |
4.7
|
5.7
|
6.0
|
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.
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