Chapter 2. A Chronology of CHW Workforce Development

Health care planners and administrators are giving increasing attention to community health workers as members of established health care teams. This chapter describes the events that, over time, marked their progressive inclusion in public and private health initiatives. A true history of community health workers would begin more than 300 years ago when communities recognized the advantages of assigning to selected gifted community members the responsibility of assisting other members in health-related matters.^[1] However, references in the literature about CHW activities are found mostly after the mid-1960s. Few studies in the 1950s described grassroots self-help projects and basic outreach and education initiatives by indigenous workers.^[2] Facts and critical events marking the evolution of those grassroots initiatives into what is now the CHW workforce have been grouped into four periods spanning the years 1966-1972, 1973-1989, 1990-1998 and 1999-2006. The list assembled here is not intended to be comprehensive but only suggestive of significant steps in the development of the CHW workforce.

Early Documentation (1966-1972)

During this period, attempts to engage CHWs in low-income communities were experimental responses to the persistent problems of the poor and were related more to antipoverty strategies than to a specific model of CHW intervention for health improvement. Few early studies described CHW effectiveness and its potential.

• The Federal Migrant Health Act of 1962 mandated outreach, but there was no substantial activity involving indigenous CHWs until the 1970s.^[3] Earlier farmworker CHW activity, funded by the former U.S. Children's Bureau, was documented in the 1950s in Florida.^[4]
• The earliest documented use of CHWs by the New York City Health Department was in a 1960s tuberculosis program involving "neighborhood health aides."^[5]
• Early Federal support of CHW activity came from the Office of Economic Opportunity (OEO) for antipoverty efforts such as "Model Cities" and the "New Careers for the Poor" under the OEO Act of 1964. In these initiatives, job creation was an important objective.^[6] Studies discussing this initiative were published as early as 1964.^[7]
• One of the CHW programs that emerged from the antipoverty initiative was the Community Health Representative Program for Native American populations. It originated under the OEO in 1968 and was gradually transferred to the Indian Health Service between 1969 and 1972.^[8]
• One of the first effectiveness studies on CHWs, in which CHWs worked with public health nurses and physicians to encourage compliance with treatment of pediatric respiratory infections, was published in 1970.^[9]
• Early university-based research on CHWs was conducted at Tulane in the late 1960s and early 1970s in partnership with Planned Parenthood of Louisiana and included an early systematic look at factors important to successful employment of CHWs.^[10]
• Although the Medicare and Medicaid Programs were introduced in this period (1965-1968), no documentation was found of any plan to incorporate CHWs into these programs.

Utilization of CHWs in Special Projects (1973-1989)

No major milestones characterize this period, but there was a steady growth of projects funded by short-term public and private grants. The projects were often linked to research and, therefore, during this period, there was a substantial increase in published studies (see Figure 6.1 in Chapter 6). The studies provided scholarly documentation of CHW potential in interventions aimed at health promotion and access to health services.

• In 1978, a World Health Organization (WHO) declaration concerning CHWs was a symbolic milestone that probably stimulated attention to this workforce in the public health sector.^[11]
• The "Resource Mothers" curriculum was developed for the Virginia Task Force on Infant Mortality during the 1980s^[12] and became one of the early CHW curricula widely distributed nationally. Indiana used the curriculum to train personnel for the State's community health worker program, which began in 1994 and focused on maternal and child health.^[13] International Medical Services for Health (INMED) developed prototype materials for the Resource Mothers programs, renamed the Resource Mothers project MotherNet in 1994, and continued to provide handbooks for lay home visitors, implementation guidelines for public and private agencies, and curricular materials for training resource mothers.^[14]
• In 1989, the Health Education Training Centers (HETC) program was created to serve primarily the U.S.-Mexico Border region and areas of high immigrant populations. The program has played an important role in promoting the utilization of CHWs in public health projects.
• University-based studies explored the potential of "natural helpers" in improving community conditions through the use of existing social networks for problem-solving and diffusion of positive health-related behaviors.^[15]

State and Federal Initiatives (1990-1998)

During this period, standardized training received greater recognition, and communication increased among CHW initiatives across categorical funding programs. Many bills were introduced at the national and State levels, but none passed.

• Arizona Health Start, in 1992, was one of the first CHW programs to receive ongoing appropriations from State general revenue.^[16]
• Training centers were opened at the Community Health Education Center in Boston in 1993^[17] and at the City College of San Francisco in 1994.^[18]
• In 1993, the New Mexico Community Health Worker Association was founded with the support of the University of New Mexico and, in 1996, began annual CHW training conferences under a 3-year development grant from the Robert Wood Johnson and Henry J. Kaiser Family Foundations.^[19] Additional associations and networks are listed in Appendix H.
• In 1993, the National Advisory Committee on Rural Health and Human Services recommended^[20] that "The Secretary should develop initiatives to broaden access and innovation in health care delivery by supporting local programs that utilize indigenous community workers and paraprofessionals as essential members of community health care delivery teams."^[21]
• In 1993, the Centers for Disease Control and Prevention (CDC) awarded a grant for one of the first national conferences on CHW programs and related community-based public health activity: "Mobilizing Resources for Practice, Policy and Research."^[22]
• In 1994, the Pew Commission for the Health Professions published a landmark descriptive study about CHWs as integral members of the health care workforce. It was excerpted in a 1995 article in the American Journal of Public Health.^[23]
• The U.S. Department of Education supported college education for CHWs through a San Francisco program that offered a Community Health Worker Certificate at the City College of San Francisco.^[24]
• Kentucky Homeplace was established in 1994 with an annual State appropriation to support "Family Health Care Advisors" to serve 58 counties, mainly rural areas in the Appalachian region.^[25]
• A 1997 report sponsored by the Annie E. Casey Foundation described the potential for employing CHWs in contracts with Managed Care Organizations.^[26]
• In 1998, the Western Arizona Area Health Education Center, a HRSA-sponsored program, began organizing annual national CHW training conferences.^[27] These conferences became a focal point for the Promotores de Salud, a distinct CHW workforce devoted to improving the health status of Latino communities.
• The Health Resources and Services Administration, Bureau of Primary Health Care organized, in 1998, the first major national outreach conference on CHW activities to discuss milestones in the field and future strategies across categorical funding programs.^[28]
• The Annie E. Casey Foundation sponsored the National Community Health Advisor Study, the first project aimed at drawing a national profile of CHWs and their work. The study was released in 1998.^[29]

Public Policy Options (1999-2006)

The first State legislation specifically addressing the CHW workforce was passed at the beginning of this period, and the language describing CHWs as "integral members of the health care delivery team," first found in the 1994 study by the Pew Commission, became frequently used with reference to CHWs. Scientific sessions with this title appeared at the American Public Health Association (APHA) Annual Meetings of 2005 and 2006.

• In 1999, CHW training and certification legislation was passed in Texas.^[30] This bill mandated pilot projects involving CHWs in Medicaid managed care as well as a feasibility study on CHW certification.
• The El Paso Community College (EPCC) Community Health Worker Program began in the fall of 2000 as a community-driven project.^[31]
• In 2000, the National Rural Health Association issued public policy statements supporting expanded roles for CHWs.^[32] Similar statements were issued in 2001 by the American Public Health Association^[33] and in 2003 by the American Association of Diabetes Educators.^[34]
• In 2000, the APHA New Professionals interest group changed its name to Community Health Worker Special Primary Interest Group (CHW SPIG).
• In January 2001, a meeting of State and Federal representatives convened in San Antonio, Texas, to discuss policy options for integrating CHWs into programs such as Medicaid, Women Infants and Children (WIC), Food Stamps and Head Start.^[35]
• In 2003, credentialing legislation (HB95) was passed in Ohio.^[36]
• Three States passed bills mandating studies of the State CHW workforce; they were released in New Mexico (2003),^[37] Virginia (2006),^[38] and Massachusetts (2005).^[39]
• In 2003, the University of Arizona (Project Jump Start), supported by the U.S. Department of Education, Fund for Improvement of Post Secondary Education (FIPSE), began the development of a standardized CHW educational program.^[40] A follow-up project, the CHW National Education Collaborative, was funded by FIPSE in 2004.^[41]
• The Institute of Medicine's 2003 report on reducing health disparities made recommendations regarding CHW roles.^[42]
• A major study in 2003 by Brandeis University recommended a central CHW role in demonstration projects to address disparities in cancer prevention and treatment.^[43] The study led to the funding of six demonstration sites for cancer Patient Navigator services to minority Medicare recipients.^[44]
• The Federal Office of Minority Health and the Agency for Healthcare Research and Quality discussed the CHW role in culturally sensitive interventions in their 2004 research agenda on cultural competence.^[45]
• In June 2005, a Patient Navigator bill was signed into law as the first major CHW legislation adopted at the Federal level.^[46]
• In 2006, the Office of Management and Budget solicited public comment on changes to be considered for the existing Standard Occupational Classification system that may include "community health worker" as an occupation. The revision will be completed by the end of 2008.^[47] Comments were submitted by the public recommending the creation of a new code for community health workers as a distinct occupation.^[48]
• A 2-year grant from the Robert Wood Johnson Foundation to the Georgetown University Law Center to create a national network of CHWs began on August 1, 2006.

[1] Rosenthal EL, Wiggins N, Brownstein JN et al. The Final Report of the National Community Health Advisor Study. Tucson (AZ): University of Arizona, 1998.; Fendall NRE. The barefoot doctors: health workers in the front line. The Round Table: The Commonwealth Journal of International Affairs 1976; 264:361-9.

[2] Giblin PT. Effective utilization and evaluation of indigenous health care workers. Public Health Rep 1989; 104 (4):361-8; Richter RW, Bengen B, Alsup PA et al. The community health worker. A resource for improved health care delivery. Am J Public Health 1974; 64 (11):1056-61; Withorn A. Serving the People. Social Services and Social Change. New York (NY): Columbia University Press 1984.

[3] Rosenthal EL et al. (1998).

[4] Johnston HL. Health for the Nation's Harvesters: A History of the Migrant Health Program in its Economic and Social Setting. Farmington Hills (MI): National Migrant Worker Council; 1985.

[5] Wilkinson DY. Indigenous Community Health Workers in the 1960s and Beyond. In: RL Braithwaite; SE Taylor, editors, translator and editor Health Issues in the Black Community. San Francisco, CA: Jossey-Bass, Inc.; 1992; p. 255-66.

[6] Meister JS, Warrick LH, deZapien JG et al. Using lay health workers: case study of a community-based prenatal intervention. J Community Health 1992; 17 (1):37-51: 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.

[7] Reiff R, Riessman F, editors. The indigenous nonprofessional, a strategy of change in community action and community mental health programs. New York (NY): Behavioral Publications, Inc.; 1964.

[8] General CHR Information, History & Background Development of the Program [Internet]. Rockville (MD): U.S. Department of Health and Human Services, Indian Health Service; [updated 2006 Mar 30/cited 2006 Oct 21]. Available from http://www.ihs.gov/NonMedicalPrograms/chr/history.cfm.

[9] Cauffman JG, Wingert WA, Friedman DB et al. Community health aides: how effective are they? American Journal of Public Health Nations Health 1970; 60 (10):1904-9.

[10] Moore FI, Stewart Jr. JC. Important variables influencing successful use of aides. Health Serv Rep 1972; 87 (6):555-61.

[11] Kahssay HM, Taylor ME, Berman PA. Community health workers: the way forward. Geneva (CH): World Health Organization; 1998.  Note:  “In 1978, the International Conference on Primary Health Care in Alma-Ata proposed the development of National CHW programmes as an important policy for promoting primary health care.  Alma-Ata signaled a significant shift in health policy that broadened the means of improving health from the delivery of services to include social, economic, and political development.” (p.2)

[12] Julnes G, Konefal M, Pindur W et al. Community-based perinatal care for disadvantaged adolescents: evaluation of the Resource Mothers Program. J Community Health 1994; 19 (1):41-53.

[13] May ML, Kash B, Contreras R. Southwest Rural Health Research Center:  Community Health Worker (CHW) Certification and Training - A National Survey of Regionally and State-based Programs. U.S. Department of Health and Human Services, Health Services and Resources Administration, Office of Rural Health Policy 2005.

[14] Minow M. Revisiting the Issues: Home Visiting. The Future of Children 1994; 4 (2):243-6.

[15] Service C, Sabler E, editors. Community Health Education: The Lay Health Advisor Approach. Durham (NC): Duke University Health Care Systems; 1979.

[16] 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.

[17] Community Health Education Center [Internet]. Boston (MA): Boston Public Health Commission; [cited 2006 Nov 01]. Available from http://www.bphc.org/programs/program.asp?b=7&p=201.

[18] Love MB, Legion V, Shim JK et al. CHWs get credit: a 10-year history of the first college-credit certificate for community health workers in the United States. Health Promotion Practice 2004; 5 (4):418-28.

[19] About Us [Internet]. Albuquerque (NM): New Mexico Community Health Workers Association (NMCHWA); 2006 [cited 2006 Nov 01]. Available from http://www.nmchwa.com/about.html.

[20] Recommendation 93-11: Train Local Health Care Workers

[21] National Advisory Committee on Rural Health and Human Services: Compendium of Recommendations by the National Advisory Committee on Rural Health. [Internet]. Rockville (MD): U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy 1993 [cited 2006 Nov 01]. Available from http://ruralcommittee.hrsa.gov/nac_comp.htm.

[22] Brownstein JN. Introductory Remarks. In: Peer Health Education Community-based Programs: Mobilizing Resources for Practice, Policy and Research: Conference Summary, February 7-8, 1993, Tucson, AZ. Arizona Disease Prevention Center and Southwest Border Rural Health Research Center.  Tucson, AZ, Rural Health Office, pp. 4-5, 1993.

[23] Witmer A, Seifer SD, Finocchio L et al. Community health workers: integral members of the health care work force. Am J Public Health 1995; 85 (8 part 1):1055-8.

[24] Community Health Works Projects At-A-Glance 2005-2006 [Internet]. San Francisco (CA): Community Health Works of San Francisco 1992 [cited 2006 Nov 03]. Available from http://www.communityhealthworks.org/projects.html#1.

[25] Center of Excellence in Rural Health - Kentucky Homeplace [Internet]. Hazard (KY): University of Kentucky Chandler Medical Center; 1999 [updated 2006 Sep 25/cited 2006 Oct 9]. Available from http://www.mc.uky.edu/RuralHealth/LayHealth/KY_Homeplace.htm.

[26] Rico C. Community Health Advisors: Emerging Opportunities in Managed Care, Annie E. Casey Foundation, Seedco--Partnerships for Community Development, 1997.

[27] Community Outreach Programs [Internet]. Somerton (AZ): Regional Center for Border Health, Inc.; 2006 [updated 2006 Jul/cited 2006 Nov 01]. Available from http://www.rcfbh.com/RCBHPrograms.htm.

[28] Ritchie D. Community Health Workers:  Building a Diverse Workforce to Decrease Health Disparities. Providence (RI): Transcultural Community Health Initiative (TCHI), Center for the Study of Race and Ethnicity in America at Brown University, Feb 17-May 17, 2004; Fox D. Strategy sessions held for the development of a national CHW organization. Connections 2002; 3 (2):5.

[29] Rosenthal EL et al. (1998).

[30] HB 1864, which became effective on 9/1/99, created the Promotora Program Development Committee (PPDC). Specifically, it stated: “The purpose of this article is to establish a temporary committee that will study certain issues related to the development of outreach and education programs for promotoras or community health workers and that will advise the Texas Department of Health, the governor, and the legislature regarding its findings.”

[31] Instructional Programs - Community Health Worker [Internet]. El Paso (TX): El Paso Community College; 2005 [cited 2006 Nov 03]. Available from http://www.epcc.edu/sites/departments/instruction/programs/community/index.html. Flores L. RE: Community Health Worker Program at EPCC [Internet]. Message to: J Martinez. 2006 Nov 8, 12:48 pm [cited 2006 Nov 08]. [1 screen].

[32] Community Health Advisor Programs: An Issue Paper Prepared by the National Rural Health Association-November 2000 [Internet]. Kansas City (MO): National Rural Health Association (NRHA); 2000 [updated 2000 Nov 10/cited 2006 Nov 01]. Available from http://www.nrharural.org/advocacy/sub/issuepapers/ipaper17.html.

[33] American Public Health Association. Policy Statements Adopted by the Governing Council of the American Public Health Association, October 24, 2001. Am J Public Health 2002; 92 (3):467-8.

[34] Albright A, Satterfield D, Broussard B et al. Position Statement on Diabetes Community Health Workers by the American Association of Diabetes Educators (AADE). The Diabetes Educator 2003; 29 (5):818-24.

[35] Sustainability conference [Internet]. San Antonio (TX): Family Health Foundation; 2001 [cited 2006 Nov 01]. Available from http://www.famhealth.org/new_page_3.htm.

[36] HB95 (125th General Assembly); under this act, the Board of Nursing was given the authority to develop and implement a certification program for community health workers and began issuing certificates in February, 2005.

[37] New Mexico Department of Health. Senate Joint Memorial 076 Report on the Development of a Community Health Advocacy Program in New Mexico. Santa Fe (NM): Department of Health, November 24, 2003.

[38] Virginia Center for Health Outreach. Final Report on the Status, Impact, and Utilization of Community Health Workers. Richmond (VA): James Madison University, Institute for Innovation in Health Human Services, 2006.

[39] MDPH (2005).

[40] Proulx DE, Collier N. Project Jump Start Curriculum Guidebook. Tucson, AZ: University of Arizona, 2003.

[41] Welcome [Internet]. Tucson (AZ): Community Health Worker National Education Collaborative (CHW-NEC); 2005 [updated 2006/cited 2006 Nov 01]. Available from http://www.chw-nec.org/bg.cfm.

[42] Finding 5-2 and Recommendation 5-10; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment:  Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): Institute of Medicine, National Academies Press; 2003.

[43] Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities. Baltimore (MD): U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2003.

[44] CMS Selects Sites For Demonstration Seeking Ways to Reduce Disparities in Cancer Health Care [Internet]. Baltimore (MD): U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services; 2006 [updated 2006 Mar 24/cited 2006 Nov 01]. Available from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1816.

[45]Report: Setting the Agenda for Research on Cultural Competence in Health Care [Internet]. Rockville (MD): U.S. Department of Health and Human Services, Office of Minority Health; 2004 [updated 2006 Jul 07/cited 2006 Nov 01]. Available from http://www.omhrc.gov/templates/content.aspx?ID=86&lvl=3&lvlID=254.

[46] HR 1812 Patient Navigator Outreach and Chronic Disease Prevention Act of 2005.

[47] Office of Management and Budget. Standard Occupational Classification-Revision for 2010; Notice. Fed Regist 2006; 71 (94).

[48] SkillWorks, The Boston Community Health Worker Initiative, Full Partnership - August 17, 2006 Minutes [Internet]. Boston (MA): Boston Community Health Worker Initiative (BCHWI); 2006 [updated 2006 Apr 17/cited 2006 Nov 02]. Available from http://www.bostonabcd.org/programs/documents/FullPartnersminutes08-17-06.doc.