During the past decade, private insurers, business enterprises and the Federal government have implemented or proposed changes in health care delivery and financing. These payers were reacting to unprecedented increases in health-related expenditures amid hypercompetitive global markets. Simply, the cost of providing adequate health care to employees and the population at large had become very high.
Some viewed the community health worker (CHW) workforce as a component of cost-effective strategies addressing the health care needs of underserved communities. However, there was little rigorous, comprehensive research about the CHW workforce.
This report describes a comprehensive national study of the community health worker workforce and of the factors that affected its utilization and development. The research began in 2004 and was concluded in 2007 by the Regional Center for Health Workforce Studies of The University of Texas Health Science Center at San Antonio under contract No. HHSH230200432032C awarded by the United States Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. The Evaluation and Analysis Branch, Office of Workforce Analysis and Quality Assurance, BHPr, HRSA, was responsible for overseeing the research project.
This report describes a comprehensive national study of the community health worker (CHW) workforce. The 27-month research project utilized a survey of verified CHW employers in all 50 States, more in-depth interviews of employers and CHWs in 4 States, conducted a comprehensive review of the literature, and made national and State workforce estimates using databases from the Census and the U.S. Department of Labor, Bureau of Labor Statistics.
During the past decade, private insurers, business enterprises, and the Federal government, responding to the high cost of providing adequate health care to employees and the population at large, implemented or proposed changes in health care delivery and financing. Some of the factors contributing to the cost challenges included population changes, provider shortages, accelerating technological progress, and the increasing complexity of the health care system. Population projections have been predicting a large increase in the U.S. elderly population (estimated to be 87 million in 2050) and, due to higher fertility among minorities, an increase in population diversity and the size of younger cohorts of individuals from low-income families. These changes in the size, structure and diversity of the population have been and will be requiring a broader range of health services for entire families and communities. Cultural understanding, community health education, and translation services have been and will be increasingly needed for delivering effective care to families and communities that are often isolated and underserved. Additionally, many providers are in short supply and have been caring for increasingly large and diverse patient populations in regulated environments that discourage patient/provider interaction and continuity of care. The diffusion of new science and technology while offering encouraging solutions has not yet reached a scale large enough to outpace providers' shortages and the escalating cost of care. However, telemedicine and new methods of disseminating scientific information have been empowering individuals with less extensive clinical training but strong personal and community skills to become valuable members of established medical teams for improving access, patient communication and compliance, outreach, prevention, and early diagnoses in underserved communities.
These converging demographic and economic forces set the stage for the emergence of the community health worker workforce and its utilization in cost containment and cost-effective strategies aimed at providing health care to the underserved.
Community health workers are lay members of communities who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. They have been identified by many titles such ascommunity health advisors, lay health advocates, "promotores(as)," outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs offer interpretation and translation services, provide culturally appropriate health education and information, assist people in receiving the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening.
Chronology of CHW workforce development
The history of community health workers is rooted in early self-preservation and self-reliance strategies by communities the world over. However, references in the U.S. literature about CHW activities are found mostly after the mid-1960s. For this study, selective lists of critical events marking the evolution of the CHW workforce have been grouped into four periods.
- During the early documentation period (1966-1972), the attempts to engage CHWs in low-income communities were experimental responses to the persistent problems of the poor and related more to antipoverty strategies than to specific models of CHW intervention for disease prevention and health care.
- The next period (1973-1989) was characterized by special projects funded by short-term public and private grants, often linked to research in universities, and produced a substantial increase in published studies documenting CHWs' potential in interventions aimed at health promotion and access to health services.
- State and Federal Initiatives (1990-1998) followed. Standardized training for CHWs received greater recognition and there was a surge of communication among CHW initiatives across categorical funding programs. Many bills in support of CHW activities were introduced at the national and State levels, but none passed.
- The latest period included significant Public Policy (1999-2006) actions. Legislation specifically addressing CHWs, their use and their certification was passed in several States and a Patient Navigator bill was signed into law as a major piece of legislation at the Federal level addressing CHW activities. Also, a 2003 Institute of Medicine report on reducing health disparities made recommendations regarding CHW roles.
Workforce size and characteristics
There is no specific occupational code that can be used in official reports for community health workers and, therefore, there are no official estimates of the number of community health workers (CHWs) in the United States. Until now, these workers have been reported under existing occupations that have similar but not equivalent job descriptions.
For this study, estimates were made of volunteer and paid CHWs in each of the 50 States, first by making an assessment of the occupations that were likely to have been used as proxies for community health worker activities in reports to the Bureau of Labor Statistics and the Census Bureau. Then, the approximate percent of individuals in those occupations likely to be CHWs was determined. The occupations included in the estimates were counseling, substance abuse, educational-vocational counseling, health education, and other health and community services. CHWs were estimated to be from 5 to 40 percent of the workers engaged in these occupation/industry categories and they were either wage earners (67 percent) or volunteers (33 percent) in not-for-profit and for-profit organizations such as schools, universities, clinics, hospitals, physician offices, individual-family-child services, and educational programs.
Approximately 86,000 community health workers assisted American communities in 2000. California and New York were home to about 9,000 and 8,000 CHWs, respectively. Texas, Florida, and Pennsylvania had between 3,500 and 5,000 CHWs each. The States of Illinois, Ohio, and Georgia had, in that order, a CHW workforce of 3,520, 3,503, and 3,250. Ten States employed approximately 2,000 CHWs each, 7 States about 1,000 CHWs and the remaining 25 States, as well as the District of Columbia, only several hundred CHWs each.
The personal and professional characteristics of CHWs were assessed through a CHW National Employer Inventory (CHW/NEI) in all 50 States, never attempted before this study. A list of contacts, verified through phone calls (2,500), received a letter of invitation and appropriate reminders to participate in a Web-based survey. The inventory represents the most comprehensive and systematic effort to date of contacting, in every State, as many organizations employing CHWs as possible.
The majority of individuals engaged in community health worker activities were either Hispanic or Non-Hispanic White (35 and 39 percent, respectively). The next largest groups were African-Americans (15.5 percent), Native Americans (5.0 percent) and Asian and Pacific Islanders (4.6 percent). Volunteer and paid CHWs had a similar racial and ethnic distribution with a somewhat higher relative proportion of Non-Hispanic Whites in the volunteer group. The majority of CHWs were female (82 percent) between the ages of 30 and 50 (55 percent). The predominance of women in this workforce was partly due to the focus of many programs on underserved children and their mothers as well as to clients' greater acceptance of female caregivers in their homes. One-fourth of the workforce was younger than 30 and one-fifth was older than 50. Volunteers were more numerous in the older groups. More than one-third of all employed and volunteer community health workers had a high school education (35 percent); about one-fifth had completed some college work (20 percent), and almost one-third had at least a 4-year college degree (31 percent). Paid and volunteer CHWs were similar across levels of educational attainment except that more volunteers had less than a high school diploma and more paid workers had completed some college.
Sixty-four percent of the positions paid new hires an hourly wage below $13; only 3.4 percent of them paid at or near the minimum wage (under $7 per hour) and 21 percent paid $15 per hour or more. The majority of experienced CHWs (70 percent) received an hourly wage of $13 or more and about half of them received more than $15 per hour, indicating that longevity and/or experience received economic recognition.
Health workers have been engaged with different job titles in different models of care. Titles and models of care ranged from those of volunteer workers seeking the general improvement of a community's health status to those of outreach workers with specific jobs aimed at reducing the impact of a single illness such as diabetes or HIV/AIDS. The common traits among these diverse roles have been found to be the commitment of these health workers to both the communities they assisted and the organizations for which they worked, the skill of interacting effectively with both, and the ability to motivate clients.
Volunteer CHWs were employed either by grassroots organizations, usually faith-based, or in outreach and health education efforts designed by university researchers and local health care providers, or in programs with ambitious goals but limiting budgets trying to maximize program impact from limited resources.
The communities receiving CHW services included all ethnic and racial groups but, most often, Hispanic/Latino (as reported by 78 percent of the respondents), Black/African-American (68 percent) and Non-Hispanic White (64 percent). One-third of the respondents reported services to American Indian/Alaska Natives and Asian/Pacific Islanders (32 and 34 percent, respectively). The clients targeted most frequently were females and adults ages 18 to 49. Special populations included the uninsured (as reported by 71 percent of respondents) followed by immigrants (49 percent), the homeless (41 percent), isolated rural residents and migrant workers (31 percent each), and colonia residents (9 percent). Programs serving immigrants, migrant workers, and the uninsured were more likely than other types of programs to have volunteer CHWs.
The most frequently reported health issues for which employers chose interventions that included CHWs were women's health and nutrition (46 and 48 percent of respondents, respectively). These issues were closely followed by child health and pregnancy/prenatal care (41 percent each), immunizations (37 percent), and sexual behavior (34 percent). Next, employers reported CHW interventions targeting specific illnesses such as HIV/AIDS (39 percent), diabetes (38 percent), high blood pressure (31 percent), cancer (27 percent), cardiovascular diseases (26 percent), and heart disease (23 percent). Programs dealing with cancer, cardiovascular disease, diabetes, and high blood pressure were more likely to have only volunteer CHWs than programs working with other conditions.
The CHW specific work activities involved culturally appropriate health promotion and health education (as reported by 82 percent of the respondents) followed by assistance in accessing medical and non-medical services and programs (84 and 72 percent, respectively) and complemented by "translating" (36 percent), interpreting (34 percent), counseling (31 percent), mentoring (21 percent) and, more generally, social support (46 percent) and transportation (36 percent). Related to these work activities, employers reported specific duties such as case management (45 percent), risk identification (41 percent), and patient navigation (18 percent), and direct services such as blood pressure screening (37 percent).
Key functional areas for CHW activity included creating more effective linkages between communities and the health care system, providing health education and information, assisting and advocating for underserved individuals to receive appropriate services, providing informal counseling, directly addressing basic health needs, and building individual and community capacity in addressing health issues.
Models of Care
The study identified five prevailing models of care engaging CHWs:
(1) Member of care delivery team. In this model, the CHW was largely subordinate to a lead provider, typically a physician, nurse, or social worker. Tasks were relatively specific and generally delegated by the lead provider.
(2) Navigator. The navigator role placed greater emphasis on the CHW's capabilities for assisting individuals and families in negotiating increasingly complex service systems and for bolstering clients' confidence when dealing with providers. The navigator model did not necessarily require a high degree of clinical supervision, but it did require a high level of awareness about the health care system. The major contribution by CHWs in this model was that of improving access and educating consumers as to the importance of timely use of primary care.
(3) Screening and health education provider. This model of care has been one of the more common, and was often included in many categorically funded initiatives on specific health conditions such as asthma and diabetes. CHWs taught self-care methods, administered basic screening instruments and took vital signs. CHWs were able to gain access to hard-to-reach populations and were willing to work in neighborhoods or rural areas where other professionals were reluctant to practice. There were concerns, however, about the quality of services and information provided by CHWs, prompting calls for strict evaluation of the CHWs' training and close supervision of their activities.
(4) Outreach-enrolling-informing agent. "Outreach worker" was a common job title for CHWs, and it addressed the need of many programs to reach individuals and families eligible for benefits or services and persuade them to apply for help or come to a provider location for care.
(5) Organizer. This model of care more often involved volunteer CHWs who became active in a community over a specific health issue, promoting self-directed change and community development. The models listed were not always mutually exclusive and the list was compiled with the intent of integrating several but not all of the existing classification schemes.
Education and training
Employers hiring community health workers have been looking for individuals with some formal education, specific qualities, and certain skills. Also, while employers have provided post-employment training for general education and specific competencies, they have not always offered opportunities for a career as a CHW. Employers reported that the languages most often used by CHWs to communicate with clients were English and Spanish (87 and 70 percent of the respondents, respectively). Less than 10 percent of the employers reported the use of French, Vietnamese, and Chinese. Few (6.4 percent) reported the use of sign language and knowledge of tribal languages (3.8 percent). Cultural competence was defined in this study as "the ability of understanding and working within the context of the culture of the community being served." This definition was easily understood and agreed upon in field-testing and by employers interviewed in the four States selected for further study. However, responses were mixed as to whether cultural competence required that the CHW be a resident of the area being served.
About half of employers had educational or training requirements for CHW positions. Twenty-one percent mentioned that at least a high school diploma or GED was expected. A Bachelor's Degree was a prerequisite to employment in 32 percent of the organizations. Most employers required post-hire training of CHW personnel through either continuing education (68 percent) with classroom instruction (32 percent) or through mentoring (47 percent) and on-site technical assistance (43 percent). The length of training reported ranged from nine to 100 hours. Employer-based training often was aimed at both enhancing the generic skills of CHWs and at the acquisition of competencies needed for specific programs. Specific training was required for understanding medical and social services, coordinating access to services, home visiting and patient "navigation," providing health education and counseling, and administering first aid and CPR. Texas was the first State to adopt legislation governing the utilization of CHWs (1999). It was followed by Ohio in 2002.
Generally, the occupation of CHW has not been viewed as a career, because CHWs have positions that are often short-term, low paid, and lack recognition by other professionals.
Since statistics on employers were not available, their total was derived from the estimates of paid and volunteer CHWs and findings from the CHW National Employer Inventory (CHW/NEI). The number of organizations employing community health workers was estimated to be 6,300 for the Nation as a whole. This rough approximation was obtained by dividing the average number of CHWs engaged by the employers surveyed for the CHW National Employer Inventory into the estimated national total of CHWs.
The industries more likely to employ CHWs were
- "Individual and Family Services" (21 percent),
- "Social Advocacy Organizations" (14.2 percent),
- "Outpatient Care Centers" (13.3 percent), and
- "Administration of Education Programs" (12.9 percent).
Additional industries found to have CHWs among their personnel, although less often, included "Other Ambulatory Health Care Services" (8.4 percent) and "Office of Physicians" (5.3 percent).
The largest percentage of the organizations engaging CHWs (43 percent) were firms employing between 5 and 19 employees. Twenty percent had between 20 and 49 individuals on the payroll, and another 19.1 percent fell in the 50 to 249 employee category. Few, 2.8 percent, employed 250 to 499 individuals and 2.3 percent had 500 or more employees. About 12.5 percent of the firms had fewer than 5 employees.
The occupational characteristics of CHWs that have been motivating employers to hire them were identified by combining findings from the employers' interviews and information gleaned from the review of the literature. Generally, employers have hired community health workers because they
(a) learned about their successful utilization in professional journals,
(b) believed that they were cost effective,
(c) found that CHWs were capable of organizing communities in developing comprehensive health action plans, or
(d) discovered that programs addressing health disparities were more effective when using one-to-one outreach by CHWs.
Community health workers were viewed as having contributed to more effective delivery of health-related services because they were
(1) effective in gaining access to hard-to-reach populations that had been avoided by other health workers;
(2) able to patiently coach clients in culturally appropriate terms and induce behavioral changes;
(3) able to successfully communicate with clients, after developing trusting and caring relationships, to impart or gather information and motivate key decisions such as participating in immunization programs; and
(4) able to address certain client needs such as adapting health regimens to family and community dynamics.
Networking has been the recruitment strategy used most often by employers (74 percent). Churches and local businesses have been successful intermediaries in attracting qualified candidates, and clinic-based programs have recruited among patients. Other recruitment methods ranged from mass mailings to partnerships with existing volunteer organizations.
Consistently, in the national Inventory, in employers' interviews and in the literature, the prevalence of short-term funding and the necessary reliance on multiple funding sources were cited by employers and other observers as major barriers to the development of the CHW workforce. Federal and State governments provided most of the funds. Private organizations, local governments, and other sources supported about one-third of the employers. HRSA funding supported many CHW programs principally through the Federally Qualified Health Centers of the Bureau of Primary Health Care (BPHC) and the Healthy Start Programs of the Maternal and Child Health Bureau (MCHB). About one-fourth of employers responding to the "funding" section of the national Inventory survey reported receiving funding from HRSA or having a HRSA-sponsored program. A growing area of support for CHWs was found to be for-profit firms, both through outsourcing or direct employment. However, most of the information on the utilization of CHWs by for-profit organizations was considered proprietary, sensitive from a competitive viewpoint, and was not available for inclusion in this study.
Research on the CHW workforce
The study described in this report marks the first research effort that used a survey of verified employers in all 50 States to draw a profile of the community health worker workforce. Over the years, there has been a significant increase in the number of published journal articles addressing CHW-related topics, from 62 articles in the 1970s to nearly 400 in the 1990s, and 299 from 2000 to 2005. However, no peer-reviewed journal exists with a specific focus on CHW practice. The quality and scope of research described in the articles varied from few rigorous evaluations of specific medical interventions utilizing CHWs to many descriptive reports of CHW programs. Many studies suffered from small sample sizes, poor research designs, and lack of control groups.
Nine literature reviews have been published between 2002 and 2006 to evaluate the use of community health workers in specific primary care and medical specialty interventions. These reviews represent the best available assessments of findings from research on health interventions that included the use of CHWs. All of the articles reviewed represent contributions to other fields such as pediatrics and health education. Most reported findings were statistically significant, but not all of them had clinical significance. Three of the nine reviews were limited to the involvement of CHWs in interventions addressing diabetes, heart disease/stroke, and pregnancy in minority women. They covered a total of 98 studies, of which 23 were included in more than one review. Two reviews included only randomized controlled trials (RCTs), and one excluded studies measuring only changes in knowledge or attitudes.
There are suggestive indications, but no statistical evidence, of the size and direction of change in the community health worker workforce. Using the estimated proportions of CHWs in selected occupations and projections from the Bureau of Labor Statistics, assuming no changes in the proportions over time, the estimate was made of 121,206 CHWs in 2005, an increase of 41 percent from 85,879 CHWs in 2000.
The majority of employers in Texas and Arizona who participated in telephone interviews were optimistic about continuing the employment of CHWs and even expanding their utilization into health care services addressing diabetes, mental health, and oral health. Few employers mentioned plans of involving CHWs in future clinics, emergency rooms, and additional geographic areas. All employers indicated that continued funding was the key determinant of continued CHW employment.
Reports from selected States
Regional workforce profiles were assembled with data gathered from published and unpublished studies and reports, special tabulations of the CHW National Employer Inventory, and 48 unstructured interviews with employers and CHWs. The results of the interviews from the larger States of New York and Texas were compared to the findings from the national Inventory and were found to reinforce those findings. The demographic characteristics of community health workers usually mirrored those of the communities they served. In Arizona, they 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. In Massachusetts, they were mostly White (80 percent). In New York, 37 percent of CHW personnel were Black/African-American, 35 percent were Non-Hispanic White, and one-fourth 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.
In the selected States, as in the Nation, CHWs were mostly female between the ages of 30 and 50. Exceptions were found in certain programs such as Arizona nutrition programs, or fatherhood, HIV case management, and some youth programs in New York, which maintained a predominance of male workers. Educational levels, wages, utilization, and models of care in the selected States are detailed in this chapter.