There are no official estimates of the
number of community health workers (CHWs)
in the United States because there is
no specific occupational code to report
them in national databases.[1]
Until now, CHWs have been counted in
official reports under existing occupations
that have similar but not equivalent job
descriptions. The distinguishing CHW roles
are those enhancing outreach and effectiveness
of health services to underserved communities.
An appropriate definition of the CHW
occupation for its inclusion in national
statistics is now being considered. Comments
were submitted by the public to the Office
of Management and Budget recommending
the creation of a new Standard Occupational
Classification (SOC) code for community
health workers. As the job descriptions
that define the community health worker
occupation are better understood and documented,
it is possible to estimate the CHW workforce
from existing data with greater confidence.
Size of the Workforce:
National and State Estimates
After 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 and of the percent
of individuals in those occupations likely
to be CHWs, estimates were made of volunteer
and paid CHWs in each of the 50 States.[2]
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 percent to 40 percent
of the workers engaged in these occupations
and they were either wage earners (67
percent)[3]
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.
The estimates, shown in Table 3.1, indicate
that in the year 2000 there were approximately
86,000 community health workers assisting
American communities. California and New
York were home to about 9,000 and 8,000
CHWs, respectively. Texas, Florida, and
Table 3.1 Estimates
of Paid and Volunteer CHWs in the United
States by States and Census Regions
Census
Region and State |
Paid
CHWs |
Volunteer
CHWs |
Total
CHWs* |
Rank
by Total CHWs |
United
States |
57,571
|
28,308
|
85,879
|
|
Northeast |
14,505
|
4,246
|
18,749
|
|
Connecticut
|
841
|
36
|
877
|
31
|
Maine
|
454
|
95
|
549
|
39
|
Massachusetts
|
2,001
|
440
|
2,441
|
10
|
New
Hampshire |
373
|
293
|
665
|
35
|
New
Jersey |
1,499
|
45
|
1,543
|
18
|
New
York |
5,889
|
2,350
|
8,239
|
2
|
Pennsylvania
|
2,962
|
658
|
3,620
|
5
|
Rhode
Island |
240
|
303
|
543
|
40
|
Vermont
|
246
|
26
|
271
|
48
|
Midwest |
13,115
|
6,929
|
20,041
|
|
Illinois
|
2,528
|
993
|
3,520
|
6
|
Indiana
|
960
|
375
|
1,335
|
21
|
Iowa
|
600
|
338
|
938
|
27
|
Kansas
|
520
|
370
|
890
|
30
|
Michigan
|
1,807
|
917
|
2,724
|
9
|
Minnesota
|
1,403
|
517
|
1,920
|
13
|
Missouri
|
1,022
|
774
|
1,796
|
15
|
Nebraska
|
437
|
437
|
873
|
32
|
North
Dakota |
176
|
360
|
536
|
41
|
Ohio
|
2,219
|
1,285
|
3,503
|
7
|
South
Dakota |
154
|
60
|
213
|
50
|
Wisconsin
|
1,289
|
504
|
1,793
|
16
|
South |
17,470
|
10,221
|
27,687
|
|
Alabama
|
617
|
274
|
892
|
29
|
Arkansas
|
496
|
308
|
804
|
34
|
Delaware
|
157
|
62
|
218
|
49
|
District
of Columbia |
410
|
162
|
572
|
37
|
Florida
|
2,650
|
1,556
|
4,205
|
4
|
Georgia
|
1,364
|
1,886
|
3,250
|
8
|
Kentucky
|
733
|
197
|
930
|
28
|
Louisiana
|
748
|
723
|
1,471
|
19
|
Maryland
|
1,310
|
544
|
1,853
|
14
|
Mississippi
|
390
|
440
|
830
|
33
|
North
Carolina |
1,410
|
557
|
1,967
|
12
|
Oklahoma
|
606
|
431
|
1,037
|
25
|
South
Carolina |
665
|
429
|
1,093
|
24
|
Tennessee
|
884
|
349
|
1,233
|
22
|
Texas
|
3,098
|
1,879
|
4,976
|
3
|
Virginia
|
1,515
|
210
|
1,725
|
17
|
West
Virginia |
417
|
214
|
631
|
36
|
West |
12,495
|
5,166
|
17,657
|
|
Alaska
|
209
|
89
|
298
|
46
|
Arizona
|
882
|
62
|
944
|
26
|
California
|
6,178
|
3,149
|
9,327
|
1
|
Colorado
|
896
|
551
|
1,447
|
20
|
Hawaii
|
272
|
30
|
302
|
45
|
Idaho
|
287
|
52
|
339
|
43
|
Montana
|
253
|
28
|
281
|
47
|
Nevada
|
234
|
99
|
333
|
44
|
New
Mexico |
497
|
74
|
571
|
38
|
Oregon
|
796
|
433
|
1,229
|
23
|
Utah
|
368
|
56
|
423
|
42
|
Washington
|
1,522
|
500
|
2,021
|
11
|
Wyoming
|
101
|
43
|
143
|
51
|
Source: U.S. Bureau of Labor Statistics
(2000); Census Public Use Microdata Data
Sample (2000); CHW National Employer Inventory
(CHW/NEI) (2006).
*May not sum to total because of rounding
and adjustments made for the estimates
of volunteer CHWs.
Pennsylvania had a workforce 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 distribution
among the four Census regions was: 22
percent of total CHWs in the Northeast,
24 percent in the Midwest, 33 percent
in the South, and 21 percent in the West.
The methodology employed to produce these
estimates is described in detail in Appendix
B.
Who are the Community
Health Workers?
Personal and professional characteristics
of CHWs were assessed through a never-before-attempted
CHW National Employer Inventory (CHW/NEI)
in all 50 States. A list of contacts (2,500),
verified through phone calls, received
letters of invitation and appropriate
reminders to participate in the survey.
The CHW/NEI - not a sample survey, impossible
since an official count of all employers
of CHWs had never been made - represents
the most comprehensive and systematic
effort to date of contacting, in every
State, as many organizations employing
CHWs as possible. A response rate of 36
percent (900 respondents) yielded the
first detailed national- and State-specific
information on CHWs and their activities.[4]
Table 3.2 displays key demographic indicators
of CHWs and Table 3.3 the wages earned
by CHWs. The findings from the CHW/NEI
did not contradict the information extracted
from the extensive review of the literature
conducted for this study.[5]
Table 3.2 Demographic
Characteristics of CHWs
Race
and Ethnicity -- N=504 |
Total
CHWs |
Paid
|
Volunteer
|
American
Indian/Alaskan Native |
5.0
|
7.0
|
0.5
|
Asian/Pacific
Islander |
4.6
|
5.9
|
1.8
|
Black/African-American
|
15.5
|
14.9
|
16.8
|
Hispanic
|
35.2
|
37.3
|
30.8
|
Non-Hispanic
White |
38.5
|
33.8
|
48.3
|
Other
|
1.2
|
1.1
|
1.4
|
Age
-- N=488 |
Less
than 30 |
25.4
|
23.8
|
28.4
|
30
to 50 |
54.8
|
59.5
|
46.1
|
Over
50 |
19.8
|
16.7
|
25.5
|
Gender
-- N=495 |
Female
|
81.6
|
85.7
|
72.0
|
Male
|
18.4
|
14.3
|
28.0
|
Education
-- N=481 |
Less
than High School |
7.4
|
4.7
|
13.5
|
High
School, GED |
34.8
|
34.4
|
35.6
|
Some
College |
20.3
|
22.4
|
15.8
|
Two-year
Degree |
6.8
|
7.0
|
6.4
|
Four-year+
Degree |
30.7
|
31.6
|
28.8
|
Source: CHW/NEI (2006).
Table 3.3 Wages
of CHWs
Hourly
Wages* |
New hires
N=387 |
Experienced workers
N=341 |
Less
than $7.00 ($14,539 or less yearly)
|
3.4
|
0.6
|
$7.00
- $8.99 ($14,560 - $18,699 yearly)
|
13.4
|
2.9
|
$9.00
- $10.99 ($18,720 - $22,859 yearly)
|
23.8
|
10.6
|
$11.00
- $12.99 ($22,880 - $27,019 yearly)
|
23.0
|
15.8
|
$13.00
- $14.99 ($27,040 - $31,179 yearly)
|
15.8
|
21.1
|
$15.00
or more ($31,200 or more yearly) |
20.7
|
49.0
|
Source: CHW/NEI (2006).
* Wages reflect data for the first CHW
of up to five job titles reported by employers.
Minimum is wage for new hire and maximum
is top range for experienced CHWs.
The majority of individuals engaged in
community health worker activities at
the organizations responding to the CHW/NEI
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 employers responding to the CHW/NEI
indicated that a majority of CHWs (55
percent) working for them were predominately
female (82 percent) between the ages of
30 and 50. 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
with two exceptions: (1) more volunteers
(13.5 percent) had less than a high school
diploma than paid CHWs and (2) more paid
workers had completed some college (22
percent) than their volunteer counterparts.
CHW positions have often been described
as low-wage. However, the employers responding
to the CHW/NEI survey reported a range
of substantially different compensation
levels. 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 (49 percent) received
more than $15 per hour, indicating that
longevity and/or experience received economic
recognition.
Additional relevant information on CHW
wages was found in the literature. According
to the Massachusetts Department of Public
Health (MDPH), in 2004, the average yearly
income for CHWs was approximately $23,000
yearly, $6,000 less than the average for
that State.[6]
The same report indicated that CHW salaries
did not increase proportionally to educational
level, work experience, or tenure. In
California, a 1998 survey of health care
providers in the San Francisco Bay Area
revealed that 26 percent of full-time
CHWs earned less than $20,000 a year,
44 percent earned between $20,001 and
$25,000, 20 percent earned between $25,001
and $30,000, and 10 percent earned more
than $30,000.[7]
Data from a 1999 multi-State research
project reported the compensation of CHWs
as ranging from $8,880 to $39,860 annually.[8]
Similar annual earnings were documented
in a 2003 job market assessment completed
in Florida, with entry-level salaries
between $17,170.98 and $27,580.89, and
an average annual salary of $22,376.[9]
A 2002 Virginia survey reported CHW median
hourly wages of $10.50.[10]
Job postings revealed that State and local
health departments in Maryland paid CHWs
a range of $20,894 to $32,093,[11]
and a "Health Worker III" in
San Francisco with a minimum of two years'
experience, holding a position similar
to that of a CHW's, was paid $1,702 to
$2,069 biweekly or $44,252 to $53,794
annually.[12]
The CHW/NEI found that the majority of
employers were paying employment benefits
to their CHW personnel. The most common
were mileage reimbursement (76 percent
of employers); health insurance and sick
leave (71 percent each); vacation accrual
(68 percent); personal leave (56 percent);
and a pension or retirement plan (54 percent).
Tuition assistance and educational leave
benefits were reported by 31 percent and
16.9 percent of employers, respectively.
These findings confirm reports from the
literature.[13]
However, in Massachusetts, many of the
CHWs indicated that health insurance was
not provided as part of their positions,
and 53 percent of the CHWs in New Mexico
relied on public health insurance or had
no health insurance coverage.[14]
How CHWs are Utilized
The utilization of community health workers
was found to reflect the definition of
their role in the health care delivery
system included in Chapter 1.
Community health workers are lay
members of communities[15]
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 as community health advisors, lay
health advocates, "promotores(as),"[16]
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.
Drafting an operational definition of
the CHW occupation has presented challenges
because these health workers have been
engaged with different job titles in different
models of care.[17]
Titles and models of care ranged from
those of volunteer workers seeking general
improvement of community health status[18]
to those of outreach workers with the
specific mission of reducing the impact
of a single illness such as diabetes or
HIV/AIDS in individuals or entire communities.[19]
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, their skill of interacting
effectively with both, and their ability
to motivate clients.
In an article in the American Journal
of Preventive Medicine, researcher John
McKnight[20]
explained that to achieve and maintain
health, it is necessary to have the harmonious
operation of two systems. The health care
system produces units of service and relies
on control and evidence-based accountability
to achieve its ends of preventing and
treating disease, but only the community
itself (the second "system")
can produce the self-motivation and supportive
relationships needed to actually produce
and maintain health.[21]
The harmonious operation of the two systems
is particularly challenging in underserved
environments, and CHWs were found to be
capable of facilitating their interactions.
In the following pages, the current utilization
of volunteer and paid community health
workers is described.
Programs with volunteer
CHWs
Programs employ volunteer CHWs for different
reasons and these determine how the volunteers
are utilized. Programs can be classified
under three models.
The grassroots organization model:
Grassroots community-based initiatives
often have been faith-based, and have
had either a broad goal, such as helping
welfare families to become self-sufficient
and to adopt healthy behaviors, or narrow
purposes such as supporting HIV-positive
individuals or substance abusers. Because
of their origins, many of these models
have not been well documented. An exception
is the network of farmworker comités
in California, supported by the Center
for Community Advocacy. This model of
community self-determination was featured
in the design of the Promotores Comunitarios,
a well-documented initiative funded in
2005 by the California Endowment in eight
rural communities.[22]
Another example was a multi-program initiative
in rural Alabama built on community assessments
and priority-setting organized by resident
committees of volunteer CHWs.[23]
The lay health advisors model:
This model is an outreach and/or health
education effort, usually designed by
university researchers or local health
care providers, with "lay health
advisors" or "natural helpers"
as part of interventions involving the
encouragement and support of naturally
occurring community-based social networks.
These models were aimed at durable changes
in knowledge, attitudes, and behaviors
that were more likely to occur when supported
by communities' social networks.[24]
The program survival model: Programs
with ambitious goals and budget constraints
have been engaging volunteer CHWs to maximize
program impact from limited resources.
Some of these programs also employed paid
CHWs as recruiters and supervisors of
volunteer CHWs and often managed a paid
and volunteer workforce.[25]
Table 3.4 shows the percent of employer
respondents to the national Inventory
who utilized only volunteers, only paid
CHWs, or a combination of volunteers and
paid CHWs.
Table 3.4 Percent
of Programs Employing Paid and Volunteer
CHWs by Census Region
Census
Region |
Paid
and Volunteer |
Volunteer
Only |
Paid
Only |
Northeast
|
25.0
|
0.7
|
74.3
|
Midwest
|
22.4
|
6.0
|
71.6
|
South
|
23.1
|
9.2
|
67.7
|
West
|
32.6
|
4.1
|
63.2
|
U.S.
|
26.3
|
5.5
|
68.3
|
Source: CHW/NEI (2006).
CHWs' Activities
and Roles
Work activities or job descriptions define
occupations. The term "role"
is used in this section to describe the
specific models of care within which CHWs
perform the "jobs" that are
part of their occupation.[26]
These models are described later in this
section. Different classification schemes
could have been used. The ones adopted
here attempt to integrate many useful
characteristics of previous analyses into
one comprehensive format.
As shown in Table 3.5, the communities
reported by employers as those where CHWs
have been utilized 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 (32 and 34 percent,
respectively) indicated that American
Indian/Alaska Native and Asian/Pacific
Islander communities have been receiving
CHW services. The clients targeted most
frequently were females and adults ages
18 to 49. Special populations receiving
CHW services 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).[27]
Programs serving immigrants, migrant workers,
and the uninsured were more likely than
other types of programs to have volunteer
CHWs.
Table 3.5 Target
Population of CHW Activities by
Percent of Respondents
Race/Ethnicity
N=587 |
Paid
Only |
Volunteer
Only |
Paid
and Volunteer |
Total
|
American
Indian/Alaskan Native |
33.3
|
11.8
|
34.4
|
32.4
|
Asian/Pacific
Islander |
35.9
|
11.8
|
34.4
|
34.1
|
Black/African-American
|
70.5
|
58.8
|
64.4
|
68.1
|
Hispanic/Latino
|
76.3
|
76.5
|
81.9
|
77.9
|
Non-Hispanic
White |
65.1
|
38.2
|
67.5
|
64.2
|
Other
|
20.6
|
17.6
|
19.4
|
20.1
|
Gender
N=587 |
Female
|
92.6
|
97.1
|
92.5
|
92.8
|
Male
|
77.1
|
76.5
|
85.0
|
79.2
|
Transgendered
|
23.4
|
8.8
|
34.4
|
25.6
|
Age
groups N=587 |
Younger
than 1 |
51.1
|
23.5
|
39.4
|
46.3
|
1-5
|
54.2
|
29.4
|
46.3
|
50.6
|
6-12
|
48.6
|
35.3
|
54.4
|
49.4
|
13-17
|
70.2
|
50.0
|
66.3
|
68.0
|
18-21
|
81.4
|
88.2
|
78.8
|
81.1
|
22-49
|
81.4
|
91.2
|
83.8
|
82.6
|
50-64
|
61.6
|
76.5
|
71.9
|
65.2
|
65
and older |
52.9
|
73.5
|
64.4
|
57.2
|
Special
Population N=587 |
Immigrants
|
48.2
|
58.8
|
47.7
|
48.7
|
Migrant
workers |
28.7
|
41.2
|
32.7
|
30.5
|
Isolated
rural residents |
28.7
|
32.4
|
37.9
|
31.4
|
Colonia
residents |
7.1
|
17.6
|
9.8
|
8.5
|
Homeless
|
40.0
|
26.5
|
45.1
|
40.6
|
Uninsured
|
68.2
|
82.4
|
73.9
|
70.5
|
Other
|
17.9
|
17.6
|
20.3
|
18.5
|
Source: CHW/NEI (2006); multiple responses
permitted.
Table 3.6 lists the most frequently reported
health issues for which employers chose
interventions that included CHWs. Women's
health and nutrition were reported by
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 work activities related to these
interventions first 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"[28]
(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), patient navigation (18 percent),[29]
and direct services (37 percent). Programs
involving case management, direct services,[30]
risk identification, and transportation
were less likely to involve only
volunteer CHWs than other programs.
Table 3.6 Health
Problems Addressed and Services Provided
by Percent of Respondents
Health
Problems N=620 |
Paid
Only |
Volunteer
Only |
Paid
and Volunteer |
Total
|
Cancer
|
22.0
|
38.2
|
36.5
|
26.8
|
Cardiovascular
disease |
22.0
|
38.2
|
32.9
|
25.8
|
Child
health |
43.4
|
26.5
|
36.5
|
40.6
|
Diabetes
|
32.9
|
55.9
|
46.1
|
37.7
|
Heart
disease |
19.6
|
38.2
|
28.7
|
23.1
|
High
blood pressure |
27.9
|
44.1
|
37.1
|
31.3
|
HIV/AIDS
|
35.8
|
17.6
|
52.1
|
39.2
|
Immunizations
|
39.6
|
23.5
|
32.9
|
36.9
|
Infant
health |
40.3
|
20.6
|
35.3
|
37.9
|
Nutrition
|
46.8
|
55.9
|
47.9
|
47.6
|
Obesity
|
31.0
|
32.4
|
38.3
|
33.1
|
Physical
activity |
27.2
|
38.2
|
29.3
|
28.4
|
Pregnancy,
prenatal care |
43.7
|
20.6
|
38.3
|
41.0
|
Sexual
behavior |
31.0
|
17.6
|
44.3
|
33.9
|
Women's
health |
44.9
|
29.4
|
52.1
|
46.0
|
Services
N=596 |
Assist
in accessing medical services/programs
|
85.0
|
85.3
|
82.7
|
84.4
|
Assist
in accessing non-medical services/programs
|
71.5
|
67.6
|
72.8
|
71.6
|
Build
community capacity |
30.8
|
38.2
|
44.4
|
34.9
|
Build
individual capacity |
33.8
|
52.9
|
48.1
|
38.8
|
Case
management |
46.3
|
32.4
|
44.4
|
45.0
|
Community
advocacy |
50.0
|
52.9
|
60.5
|
53.0
|
Counsel
|
29.8
|
20.6
|
34.6
|
30.5
|
Cultural
mediation |
17.8
|
29.4
|
16.0
|
18.0
|
Interpretation
|
33.5
|
35.3
|
33.3
|
33.6
|
Mentor
|
18.8
|
11.8
|
27.2
|
20.6
|
Patient
navigation |
16.0
|
29.4
|
19.8
|
17.8
|
Provide
culturally appropriate health promotion/education
|
81.3
|
79.4
|
83.3
|
81.7
|
Provide
direct services |
37.8
|
14.7
|
41.4
|
37.4
|
Risk
identification |
39.8
|
17.6
|
48.8
|
40.9
|
Social
support |
43.3
|
52.9
|
50.6
|
45.8
|
Translation
|
36.5
|
26.5
|
35.2
|
35.6
|
Transportation
|
35.8
|
20.6
|
38.3
|
35.6
|
Other
|
10.3
|
5.9
|
12.3
|
10.6
|
Source: CHW/NEI (2006); multiple responses
permitted.
The work activities listed in the Inventory
questionnaire were the result of literature
reviews, the judgment of individuals knowledgeable
about CHWs, and field testing with employers
and community health workers. A 2003 literature
review of 18 programs[31]
includes a list of CHW duties corresponding
to specific health intervention strategies
(Table 3.7) that complements the list
of health issues in Table 3.6 by indicating
the type of programs utilizing CHWs and
providing examples of their duties.
Table 3.7 Program
Component Description with Community Health
Worker Duties
Program
Component |
Description
|
Community
Health Workers' Duties (Example) |
Outreach
|
Reaching
persons and groups beyond and exceeding
those customarily contacted |
Case
finding/locate cases; conduct health
screening; schedule appointments;
make follow-up calls; send reminder
cards; refer as needed; staff mobile
units; network in the community with
peers |
Culturally
sensitive care |
Use
knowledge of language, cultural practices,
beliefs, etc., to structure appropriate
plan of care and strengthen therapeutic
alliance |
Translate
language; link peers and professionals
through liaison activities; develop/select
culture-specific health materials
for peers; establish/begin new services/programs;
train health professionals on culture
|
Health
education/ counseling |
Impart
knowledge and develop critical reasoning
to enable health decision-making and
to advise, recommend, suggest |
Educate/counsel
in groups or one on one; coordinate
mass media campaigns: articles, newsletters,
brochures, video, radio, etc.; develop
and distribute resource guide |
Health
advocacy |
Promote
and encourage positive health behaviors
among peers |
Serve
as role model; mentor; do crisis intervention;
lobby |
Home
visits |
Meet
peers in their home, thus reducing
barriers to care |
Sojourn;
evaluate home environments; give social
support (and other duties, see above)
|
Health
promotion/ lifestyle change |
Employ
behavior change strategies in group
or individual meetings |
Be
a leader/coach |
Perinatal
care |
Support
perinatal health of mother and child
during prenatal, delivery, and postpartum
period |
Provide
outreach/early prenatal care, nutrition,
parenting and child care |
Transportation/homemaking
|
Provide
health-related transportation; home
chores |
Drive/arrange
for travel; help with cleaning/food
preparation |
Source: Nemcek MA et al. (2003, p.262).
Key areas
of CHW activity
1. Creating more effective linkages between
communities and the health care system
Gathering information for medical
providers."Maternal-Child Health
Advocates" worked in teams with a
public health nurse in Chicago to identify
health problems and health care deficits.[32]
Educating medical and social service
providers about community needs. CHWs
in Ingham County, Michigan, identified
the need for customizing primary care
services to new enrollees in the Ingham
Health Plan (IHP) and were empowered to
use appointment slots dedicated to new
enrollees, making the primary care system
more user-friendly.[33]
Translating literal and medical languages.Some
bilingual "community health advisors"
(CHAs) provided literal translation from
one language to another or, more commonly,
explained medical terms to patients. Actual
interpretation during patient-provider
encounters was viewed as potentially inappropriate
for a CHW without rigorous training.[34]
2. Providing Health Education and Information
Teaching basic concepts of health
promotion and disease prevention.
CHWs have been utilized effectively in
delivering basic health messages in a
culturally appropriate way. Promotores(as)
in one migrant farmworker project were
responsible for distributing protective
eyewear and conducting regular eye safety
trainings.[35]
In one health promotion program emphasizing
nutrition and physical activity for older
women, each CHW worked with 20 participants
whom they contacted every two weeks and
motivated to join walking groups.[36]
Helping to manage chronic illness.CHWs
in one pediatric asthma demonstration[37]
project participated in a standardized
system of care based on the National Asthma
Education and Prevention Program (NAEPP)
Expert Panel Report Guidelines for the
Diagnosis and Management of Asthma.[38]
3. Assisting and Advocating for Underserved
Individuals to Receive Appropriate Services
Case finding.In one substance
abuse program, CHWs were able to gain
access to high-risk neighborhoods, recruit
intravenous drug users (IDUs) as study
participants, deliver educational interventions,
and gather initial and follow-up data
from participants in those neighborhoods,
achieving a 75 percent completion rate
for follow-ups.[39]
Helping clients to ask for and receive
the services they need. This role
was found to be especially important for
mental health services.[40]
Also, CHWs were reported to be effective
in promoting the use of childhood immunization
services. In one program, trained volunteer
CHWs assisted identified families with
referrals, provided reminders, and tracked
clients to immunization services through
home visits and telephone contacts.[41]
Making referrals. CHWs in a Seattle
hypertension program identified at-risk
individuals by conducting blood pressure
screenings in community locations, providing
referrals and appointment assistance,
providing appointment reminders, and assisting
in resolving barriers to obtaining care.[42]
Advocating for individuals."Resource
Mothers" (RM) in South Carolina recruited
pregnant teens through community presentations
and other outreach and became their advocates
in obtaining the prenatal care they needed.[43]
Advocating for community needs.In
one breast cancer screening program, volunteer
"lay health advisors" (LHAs),
supervised by paid CHWs, developed their
own strategies for outreach to African-American
women including training sessions for
physician practices, community health
centers, and local health departments.[44]
Providing follow-up.CHWs in one
heart health program took over non-emergency
cases with elevated blood pressure, took
vital signs, provided education, and identified
barriers to access and appointment keeping.
CHW notes were recorded in the patients'
charts. The CHWs also conducted telephone
reminders of follow-up appointments.[45]
4. Providing Informal Counseling
Providing individual support.Self-efficacy,
fostering individuals' or communities'
capability to accomplish desired changes
or actions, has been a key goal of the
CHW's support function.[46]
Maternal outreach worker programs such
as North Carolina's "Baby Love Maternal
Outreach Worker (MOW) Program" provided
support during pregnancy, including encouragement
of positive behaviors and development
of parenting skills, and were found to
reduce the occurrence of depression.[47]
Leading support groups.CHWs performed
either clinic-based counseling sessions
or home visits and discussion group sessions
to provide direct support and encourage
the use of the patient's immediate social
network in following treatment regimens.
These interventions produced significant
and sustained improvements in appointment
keeping and blood pressure control.[48]
"Native Sisters," a volunteer
CHW model with Native American women in
the Denver area, focused on increasing
breast cancer screening rates. This was
carried out by having volunteers lead
traditional social support circles.[49]
5. Directly Addressing Basic Needs
Providing limited clinical services.
Some CHWs were trained in taking vital
signs. Others were trained to provide
first aid and CPR, an important service
in remote rural areas. Community health
representatives in the Indian Health Service
have been cross-trained as emergency medical
technicians.[50]
Meeting basic needs. A CHW-driven
survey led to planning and implementation
of a farmers' market that increased access
to more healthful foods.[51]
6. Building Community Capacity
in Addressing Health Issues
Building individual capacity. CHWs
practiced nonjudgmental listening, identification
of the clients' resources, and step-by-step
skills development leading to the clients'
ability to advocate for their families.[52]
Building community capacity. CHWs
in one program were involved in community
research and planning, directed educational
services, and contributed to the development
of grant proposals. The investigators
suggested that this model of capacity-building
could be translated into an application
of "stages of change" theory.[53]
Models
of Care Utilizing CHWs
The five prevailing models of care engaging
CHWs and identified during this study
were (1) member of care delivery team,
(2) navigator, (3) screening and health
education provider, (4) outreach/enrolling/informing
agent, and (5) organizer. These models
were not always mutually exclusive. This
classification, like the one listing CHW
activities, attempts to integrate other
classification schemes.
(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. This model was commonly
applied to case management. The
lead provider often was the "case
manager of record." However, the
CHW, in some cases, had considerable responsibility
for coordination of care. The CHW's contribution
in this model was that of a more efficient
vehicle for certain team tasks
such as patient-provider communication,
including tracking patients with unreliable
addresses, limited telephone access, or
lack of transportation. A significant
benefit sought from this model was the
enhanced productivity of the medical
team.[54]
In a diabetes program in Baltimore, CHWs
made weekly contacts by phone or home
visitations to reinforce treatment regimens
and assure regular contact with primary
care providers.[55]
In another program, the CHWs' main responsibilities
were to monitor participant and family
behavior, reinforce adherence to prescribed
regimens, and provide feedback. CHWs in
a childhood immunization program located
eligible families by reviewing medical
records, maintained a tracking system
on immunization status, and used postcards,
telephone reminders, and home visits with
non-responsive parents. They managed a
caseload averaging 300 children per worker.[56]
In another example, the CHW was the coordinator
of health services for the patient. The
CHWs' duties were to maintain regular
contact with assigned patients and assist
in developing care plans. CHWs assisted
clients to resolve issues that created
barriers to care.[57]
(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. A contribution
by CHWs in this model was that of improving
access and educating consumers as to the
importance of timely use of primary care.
Navigators for the Gateway to Care Collaborative
in Houston, Texas, had specific goals
of encouraging individuals to seek services
at the lowest level of care appropriate
to the health problem, utilize services
that prevented disease, improve patient-provider
communication, and reduce inappropriate
emergency room visits. Navigators were
also responsible for assisting individuals
in developing family preventive care plans.[58]
(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.[59]
There were concerns, however, about the
quality of services and information provided
by CHWs, resulting in calls for strict
evaluation of the CHWs' training and close
supervision of their activities. Ohio's
CHW certification regulations included
standards for quality of care by CHWs.[60]
(4) Outreach/enrolling/informing agent
"Outreach worker" has been
a common job title for CHWs, and it addressed
the need of many programs to reach individuals
and families who were eligible for benefits
or services and to persuade them to apply
for benefits or come to a provider location
for care.
(5) Organizer
This model of care more often involved
volunteers rather than paid CHWs. These
volunteers became active in the community
over a specific issue, promoting self-directed
change and community development.[61]
[1]
Data on the American workforce are collected
by Federal and State agencies using the
2000 Standard Occupational Classification
(SOC) System, which provides a means to
compare occupational data across agencies.
In the SOC, all workers are classified
into one of more than 820 occupations
according to their occupational definition.
A job description -- indicating job duties,
skills, education or experience required
to perform that job -- explains each occupation.
The SOC does not contain a “community
health worker” code and job description.
Consequently, CHWs have been undetected
by official National and regional data
collection programs and, since, by law,
all paid employees must be reported by
employers, CHWs have been counted under
existing occupational classifications.
Individuals filling out U.S. Census Bureau
questionnaires have been describing their
activities as community health workers,
which later have been coded under an existing
SOC code.
[2] The codes used to
identify CHWs from the two data sets were
chosen by matching job descriptions of
CHW activities in the relevant literature
with those in the 2000 SOC system, by
asking experts, and by using information
gathered in conducting the CHW employer
inventory described later in this chapter.
The results reported in this study are
based on the 2000 Staffing Patterns data
collected by the U.S. Bureau of Labor
Statistics (BLS) and the Public Use Microdata
Data Sample (PUMS, 2000) collected by
the U.S. Census Bureau. Estimates of
paid CHWs were made using both the Census
and the BLS data sets. Estimates of volunteer
CHWs were made using the findings from
the CHW National Employer Inventory conducted
for this study and described later in
this chapter. The estimates for the Nation,
using the two independent data sources,
differed only by 6.1 percent. Larger
differences were found for some single
States. The totals shown in Table 3.1
are an average of estimates from the two
data sets. In Appendix B, the methodology
of the estimates is described in detail.
[3] CHW National Employer
Inventory (CHW/NEI) (2006).
[4] The online CHW/NEI
was conducted in partnership with the
Center for Sustainable Health Outreach
(CSHO) of The University of Southern Mississippi,
which, independently from this study,
had begun working on a National Inventory
of CHW Programs. The research team at
The Regional Center for Health Workforce
Studies (RCHWS) of The University of Texas
Health Science Center at San Antonio developed
and implemented an extensive verification
and enhancement protocol to refine the
original list of contacts provided by
CSHO, which took responsibility for sending
invitations and reminders and making follow-up
calls. The tabulation of the responses
were made specifically and exclusively
for this study. The Inventory process
is included in Appendix C and a copy of
the questionnaire is available in Appendix
D.
[5] Love MB, Gardner
K. The Emerging Role of the Community
Health Worker in California. Results
of a Statewide Survey and San Francisco
Bay Area Focus Groups on the Community
Health Workers in California's Public
Health System. Community Health Works
of San Francisco, California Department
of Health Services, 1992; Rosenthal EL,
Wiggins N, Brownstein JN et al. The Final
Report of the National Community Health
Advisor Study. Tucson (AZ): University
of Arizona, 1998; Virginia Center for
Health Outreach. Community Health Advisor/Worker
Program Survey. Harrisonburg (VA): James
Madison University, June 2002; 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; Prince JA. Job Market Assessment
of Family Health and Support Workers:
Hillsborough, Orange and Pinellas Counties
Maternal and Child Services - Workforce
Development Program, The Lawton and Rhea
Chiles Center for Healthy Mothers and
Babies, Hillsborough Community College,
and St. Petersburg College, October 2003;
Cowans S. Bay Area Community Health Worker
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(CA): San Francisco State University,
2005. 29 p; Keane D, Nielsen C, Dower
C. Community health workers and promotores
in California. San Francisco (CA): UCSF
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Community Health Workers: Essential to
Improving Health in Massachusetts, Findings
from the Massachusetts Community Health
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Austin (TX): Texas Department of State
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[6] MDPH (2005).
[7] Love MB, Gardner
K, Legion V. Community health workers:
who they are and what they do. Health
Educ Behav 1997; 24 (4):510-22.
[8] Zuvekas A, Nolan
L, Tumaylle C et al. Impact of community
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[9] Prince JA (2003).
[10] VCHO (2002).
[11] Community Health
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Baltimore (MD): Office of Human Resources,
Maryland Department of Health and Mental
Hygiene; 1996 [updated 2006 Jul 14/cited
2006 Oct 19]. Available from http://www.dhmh.state.md.us/testingserv/html/opencont/0206.htm.
[12] San Francisco Department
of Public Health: Employment Opportunities
[Internet]. San Francisco (CA): Department
of Public Health, City and County of San
Francisco; 2005-2006 [updated 2006 Oct
19/cited 2006 Oct 20]. Available from
http://www.dph.sf.ca.us/emplymnt/genljobs.htm#500Class.
[13]Prince JA (2003);
Cowans S (2005).
[14]MDPH (2005); NMDH
(2003).
[15] The term “community”
is used in a geographic sense describing
people living together in a particular
area as small as, but not necessarily
limited to, a neighborhood, who have some
common characteristics and are unified
by common interests.
[16] The terms promotores
and promotoras are used in Mexico,
Latin America, and Latino communities
in the United States to describe advocates
of the welfare of their own community
who have the vocation, time, dedication
and experience to assist fellow community
members in improving their health status
and quality of life. Recently, the term
has been used interchangeably, despite
some opposition, with the term community
health workers.
[17] Eng E, Young R.
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[18] Many interest groups
such as the Community Health Worker Special
Primary Interest Group (CHW SPIG) of the
American Public Health Association give,
in defining the CHW occupation, special
emphasis to CHWs as “frontline public
health workers” and to their impact on
“building individual and community capacity”
(in a recent recommended definition by
the Policy Committee Chair, July 2006).
Altpeter M, Earp JAL, Bishop C et al.
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[19] Altpeter M et al.
(1999).
[20] McKnight JL. Two
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communities. Am J Prev Med 1994; 10 (3
Suppl):23-5.
[21] McKnight contended
that we need both “tools” – the health
care system and community-based initiatives
– to achieve and maintain health, as the
health care system cannot produce
health and the community must do that
for itself. Health care systems need/want
changes in client behavior – clients who
utilize services appropriately, keep appointments,
follow provider instructions and practice
healthful behaviors; they also need better
information in order to manage risk –
information about the quality of care
currently provided, emerging health problems
in the population, and a better understanding
of community-generated health risks.
Communities need/want improved access
to services, information and assistance
on self-care and obtaining benefits, improvements
in overall community conditions and individual/family
opportunities, and a general sense of
control over their environments.
[22] Rose D, Quade B.
The Agricultural Worker Health and Housing
Program: Informing the Community. Los
Angeles (CA): The California Endowment,
April 2006.
[23] Raczynski JM, Cornell
CE, Stalker V et al. Developing community
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[24] Earp JA, Eng E,
O'Malley MS et al. Increasing use of mammography
among older, rural African American women:
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Spatz TS, Stotts RC et al. Increasing
mammography practice by African American
women. Cancer Pract 1999; 7 (2):78-85;
Burhansstipanov L, Dignan M, Wound D et
al. Native American recruitment into breast
cancer screening: the NAWWA Project. J
Cancer Educ 2000; 15 (1):28-32; McQuiston
C, Flaskerud JH. "If they don't ask
about condoms, I just tell them":
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EL, Harlan C, Eng E et al. Assessing the
effectiveness of lay health advisors with
migrant farmworkers. Fam Community Health
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[25] Andersen M, Yasui
Y, Meischke H et al. The effectiveness
of mammography promotion by volunteers
in rural communities. Am J Prev Med 2000;
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Namerow P et al. Impact of community volunteers
on immunization rates of children younger
than 2 years. Arch Pediatr Adolesc Med
1999; 153 (5):518-24; Brown SA, Garcia
AA, Kouzekanani K et al. Culturally competent
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