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News & Information
CDC Statements on Diabetes Issues
Community Health Workers/Promotores de Salud:
Critical Connections in Communities
Source: The following questions and answers are taken from a detailed
paper on Community Health Workers/Promotores
de Salud: Critical Connections in Communities, 2003.
1. What is a community health worker?
Community health workers (CHW) are also known as community health
advocates, lay health educators, community health representatives, peer
health promoters, community health outreach workers, and in Spanish,
promotores de salud. They are “community members who work almost exclusively
in community settings. They serve as connectors between health care
consumers and providers to promote health among groups that have
traditionally lacked access to adequate health care."
—Witmer 1995, p. 1055
2. What are some typical duties of CHWs?
- They strengthen already existing community network ties.
- They live in the communities in which they work, understand what is
meaningful to those communities, and communicate in the language of the
people.
- They recognize and incorporate cultural buffers.
- They build partnerships with formal health care delivery systems
to connect people with the services they need.
- They educate providers about the community’s health needs and the
cultural relevancy of interventions.
- They can feasibly help reduce health care and personal costs as they
help improve outcomes for community members.
3. What are core services of CHWs that were identified by the National
Community Health Advisor Study, conducted by the University of Arizona and
the Annie E. Casey Foundation (published in 1998)?
- Bridge cultural mediation between communities and the health care
system.
- Provide culturally appropriate and accessible health education and
information, often by using popular education methods.
- Assure that people get the services they need.
- Provide informal counseling and social support.
- Advocate for individuals and communities within the health and social
service systems.
- Provide direct services, such as basic first aid, and administer
health screening tests.
- Build individual and community capacity.
4. Is there a database of CHW programs?
The Centers for Disease Control and Prevention provided leadership in
documenting and acknowledging the role of CHWs, establishing the first
national database in 1993. It includes CHW programs, training centers, and
journal articles on models, research, and practice information. The
Combined Health Information Database (CHID)
has documented more than 200 programs, representing about 10,000 CHWs. In
2002, the CHW programs supported by the Bureau of Primary Health Care in the
Health Resources and Services Administration
(HRSA) were added to the database.
In May 2003, the Center for
Sustainable Health Outreach* began a project to collect information
about U.S. CHW programs. The center collaborated with the University of
Southern Mississippi/Hattiesburg and the Harrison Institute for Public Law
of Georgetown University, Washington, DC. They will soon have a form on
their Web site to submit information about CHW programs that will be
included in their database and in the CDC
CHID. Project directors can also submit information via mail, fax, or
telephone interview. For more information, E-mail Paul.Philpot@usm.edu or
call 601-266-6709, fax 601-266-6262, or write USM CSHO, Attn: Paul Philpot,
Box 10015, Hattiesburg, MS 39406-0015.
5. Why are CHWs important regarding diabetes?
The epidemic of type 2 diabetes is exacting a staggering toll on
individuals, families, and communities in the United States and,
increasingly, around the world. In the United States, the burden is
disproportionately borne by American Indian and Alaska Natives, African
Americans, Hispanic or Latino Americans, and Asian and Pacific Islanders.
Many health programs are turning to CHWs for their unique ability to
serve as “bridges” between community members and health care services
(Satterfield, Burd, Valdez, Hosey, & Eagle Shield 2001). Recognition of the
roles, skills, and contributions of CHWs; support for programs, including
stable funding, technical assistance, and evaluation; and continuing
education are needed to respectfully and effectively integrate these workers
into the health care delivery system (Witmer 1995).
6. What are some examples of CDC initiatives involving CHWs?
- The U.S.-Mexico Border Diabetes
Prevention and Control Project’s Intervention Phase 2 involves
promotores de salud in a diabetes health promotion intervention at the
family unit level. This project has been guided by the recommendations of
the National Hispanic/Latino
Diabetes Initiative for Action Recommendations report (1997).
- Evaluation of a diabetes curriculum developed by Midwest Latino
Research and Training Center, in collaboration with CDC, demonstrated
improvement of glucose control among Hispanic and Latino persons living
with diabetes. A CHW specially trained in diabetes care and education
taught the curriculum and provided social support to participants
throughout the 24-month evaluation period.
- Project DIRECT has used
community exercise leaders (DIRECT is an acronym for Diabetes Intervention
Reaching and Educating communities Together).
- The Native Diabetes
Wellness Program’s activities in developing a directory of CHW
resources and a video illustrating CHWs in action.
7. What evidence shows the effectiveness of CHWs in diabetes education and
self-care?
The use of CHWs in health intervention programs has been associated with
improved health care access, prenatal care, pregnancy and birth outcomes,
client health status, health- and screening-related behaviors, as well as
reduced health care costs (Brownstein 1998). A growing body of evidence
documents the effectiveness of CHWs in diabetes care and education efforts.
Some examples follow:
- A 6-month self-management program for patients with chronic disease
who worked with lay health instructors resulted in improved health
behaviors, improved health status, and fewer hospitalizations compared
with usual care (Lorig et al. 1999).
- 44 clients with diabetes in St. Louis, Missouri, who accepted a home
health aide to support their self-care for 18 months showed improved
glycemic control and attendance at eye and diabetes clinic visits, and
fewer emergency room visits compared with a control group (Hopper, Miller,
Birge, & Swift 1984).
- Hispanic clients who were assigned to a CHW intervention group were
more likely than those who were not to complete their diabetes education
programs (Corkery et al. 1997; Brown & Harris 1995).
- More than 100 Spanish-speaking persons using peer educators
demonstrated improved diabetes education and self-care (Lorig & Gonzalez
2001).
8. What are CDC’s goals and recommendations for CHWs?
Based on a review of the literature and on CDC’s experience with
strategies involving CHWs, the internal workgroup identified these goals and
recommendations:
- Build stronger support for CHWs that is integrated within diabetes
health care teams and programs
- To serve as bridges between the health care system and people living
with and at risk for diabetes; and
- To provide support for diabetes control programs, community-based
organizations, and other agencies instrumental in establishing these
links.
- Create educational opportunities, including ongoing technical
assistance for CHWs with diabetes training designed to help them
- To promote actions that enable community members to access care that
meets standard recommendations for diabetes care and prevention; for
example, receiving annual eye and foot exams and regular A1C testing;
- To develop and communicate culturally and linguistically appropriate
messages on diabetes self-care and community action;
- To provide social support to community members as they adapt their
lifestyles, through counseling and motivational interviewing; and
- To mobilize their communities for social action to address diabetes
on several levels; for example, in social and political situations.
- Value the contribution CHWs can make in educating health care
providers about a community’s needs, the relevance of interventions, and
cultural competence.
- Promote sustainability of CHW models by means that include the
following:
- Develop public health policy, appropriate management practices, and
other innovations, such as policies and recommendations, that recognize
and support the role of CHWs; and
- Share evidence of successful programs in various communication
channels; for example, in local newspapers and radio stations, state and
national conferences, and peer-reviewed publications.
- Apply the seven core services provided by CHWs (identified through the
National Community Health Advisor study) and their related skills and
qualities to guide development of CHW-related programs.
- Support evaluation of CHW models related to diabetes prevention and
care.
- Support CDC’s National Center for Chronic Disease Prevention and
Health Promotion to increase the engagement of CHWs in theory and practice
for strategies to help eliminate health disparities, and make possible the
means
- To develop and maintain a CHW database;
- To identify and share common “best processes” of CHW programs;
- To create educational and networking opportunities for CHWs; and
- To provide assistance with CHW-involved community-based evaluations.
* Links to non-Federal organizations are provided solely
as a service to our users. Links do not constitute an endorsement of any
organization by CDC or the Federal Government, and none should be inferred.
The CDC is not responsible for the content of the individual organization
Web pages found at this link.
References
Brown SA, Harris CL. (1995). A community-based, culturally sensitive
education and group-support intervention for Mexican Americans with
non-insulin-dependent diabetes: a pilot study of efficacy. Diabetes Educ,
21, 203-210.
Brownstein, JN(1998). The challenge of evaluating CHA services. In:
Rosenthtal EL, Wiggins N., Brownstein JN, Meister J, Rael R., de Zapien, G
et al., editors. Report of the National Community Health Advisor Study.
Baltimore, MD: University of Arizona Press, pp. 50-74.
Corkery E, Palmer C, Foley ME, Schecter CB, Frisher L, Roman SH. (1997).
Effect of a bicultural community health worker on completion of diabetes
education in a Hispanic population. Diabetes Care, 20,
254-257.
Hopper SV, Miller JP, Birge C, Swift J. (1984). A randomized study of the
impact of home health aides on diabetes control and utilization patterns.
Amer J Public Health 74, 600-602.
Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW Jr, Bandura A,
Gonzalez VM, Laurent DD, Holman HR. (2001). Chronic disease self-management
program: 2-year health status and health care utilization outcomes. Med
Care 39(11):1217-23.
Lorig, K, Sobel, DS, Stewart AL, Brown, BW, Bandura, A., Ritter P,
Gonzalez VM, Laurent DD, & Holman HR. (1999). Evidence suggesting that a
chronic disease self-management program can improve health status while
reducing hospitalization: A randomized trial. Med Care, 37, 5-14.
Satterfield DW, Burd C, Valdez , Hosey G, Eagle Shield J. (2002). The
"in-between" people: participation of community health representatives in
diabetes prevention and care in American Indian and Alaskan Native
communities. Health Promot Pract, 3 (2): 166-175.
Witmer A. (1995). Community health workers: integral members of the
health care work force. Am J Public Health, 85, 1055-58.
Historical
Page last modified: December 20, 2005
Content Source: National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes Translation
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