Chapter 3. The Community Health Worker Workforce

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

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

Source: CHW/NEI (2006).

Table 3.3 Wages of CHWs

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

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

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

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

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 Study. [HED 892 - Final Report]. San Francisco (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 Center for the Health Professions, 2004; 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; Community Health Workers in Texas Demographic Data. Austin (TX): Texas Department of State Health Services, March 2006.

[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 health workers on access, use of services, and patient knowledge and behavior. J Ambulatory Care Manage 1999; 22 (4):33-44.

[9] Prince JA (2003).

[10] VCHO (2002).

[11] Community Health Outreach Worker II (0206) [Internet]. 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. Lay health advisors as community change agents. Fam Community Health 1992; 15 (1):24-40; Friedman AR, Butterfoss FD, Krieger JW et al.  Allies community health workers: bridging the gap. Health Promot Pract 2006; 7 (2 Suppl):96S-107S; Nichols DC, Berrios C, Samar H. Texas' community health workforce: from state health promotion policy to community-level practice. Prev Chronic Dis [Serial Online] 2005; 2:1-7; Love MB et al. (1992); Blue Cross Foundation. Critical Links:  Study Findings and Forum Highlights on the Use of Community Health Workers and Interpreters in Minnesota. Eagan (MN): Blue Cross and Blue Shield of Minnesota Foundation, 2003; Brownstein JN, Bone LR, Dennison CR et al. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J of Prev Med 2005; 29 (5S1):128-33; Swider S. Outcome effectiveness of community health workers: an integrative literature review. Public Health Nurs 2002; 19 (1):11-20; Nemcek MA, Sabatier R. State of evaluation: community health workers. Public Health Nurs 2003; 20 (4):260-70; Andrews JO, Felton G, Wewers ME et al. Use of community health workers in research with ethnic minority women. J Nurs Scholarsh 2004; 36 (4):358-65; Health Resources and Services Administration. A literature review and discussion of research studies and evaluations of the roles and responsibilities of community health workers (CHWs). Maternal and Child Health Bureau, Health Resources and Services Administration,  U.S. Department of Health and Human Services, July 5, 2002; Lewin SA, Dick J, Pond P et al. Lay health workers in primary and community health care. Cochrane Database of Systematic Reviews, 2005; Norris SL, Chowdhury FM, Van Le K et al. Effectiveness of community health workers in the care of persons with diabetes. Diabet Med 2006; 23 (5):544-56; Pew Health Professions Commission. Community Health Workers: Integral Yet Often Overlooked Members of the Health Care Workforce. San Francisco (CA): University of California Center for the Health Professions, 1994; MDPH (2005); 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; Alcalay R, Alvarado M, Balcazar H et al. Salud para su corazon: a community-based Latino cardiovascular disease prevention and outreach model. J Community Health 1999; 24 (5):359-79.

[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. Lay health advisor activity levels: definitions from the field. Health Educ Behav 1999; 26 (4):495-512.

[19] Altpeter M et al. (1999).

[20] McKnight JL. Two tools for well-being: health systems and 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 capacity and improving health in African American communities. Am J Med Sci 2001; 322 (5):269-75.

[24] Earp JA, Eng E, O'Malley MS et al. Increasing use of mammography among older, rural African American women: results from a community trial. Am J Public Health 2002; 92 (4):646-54; Erwin DO, 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": a descriptive case study of Latino lay health advisers' helping activities. Health Educ Behav 2003; 30 (1):79-96; Watkins EL, Harlan C, Eng E et al. Assessing the effectiveness of lay health advisors with migrant farmworkers. Fam Community Health 1994; 16 (4):72-87.

[25] Andersen M, Yasui Y, Meischke H et al. The effectiveness of mammography promotion by volunteers in rural communities. Am J Prev Med 2000; 18 (3):199-207; Barnes K, Friedman S, 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 diabetes self-management education for Mexican Americans: the Starr County border health initiative. Diabetes Care 2002; 25 (2):259-68; Fernandez-Esquer ME, Espinoza P, Torres I et al. A su salud:  a quasi-experimental study among Mexican American women. American Journal of Health Behavior 2003; 27 (5):536-45; Krieger J, Castorina J, Walls M et al. Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention. Am J Prev Med 2000; 18 (2):123-31.

[26] In the literature, the term “role” is also used as a synonym for “functions” or “activities.”  The semantic differences are noted and accounted for in reporting the findings from the literature review.

[27] The term colonia and its plural, colonias, mean, in Spanish, community(ies) or neighborhood(s).  In the United States, these terms are being used to describe low-income or economically distressed residential areas along the United States/Mexico Border and in other regions in the country that may lack some of the most basic living necessities, such as potable water and sewer systems, electricity, paved roads, and safe and sanitary housing.

[28] As explained later in this chapter, “translation” services address both linguistic and cultural mediation.

[29] “Navigation” is a new term/work-activity that indicates specific guidance in using the health care system and which many respondents most likely considered a synonym of “assisting in accessing medical services.”

[30] Examples include taking vital signs and blood pressure screenings.

[31] Nemcek MA et al. (2003).

[32] Nacion KW, Norr KF, Burnett GM et al. Validating the safety of nurse-health advocate services. Public Health Nurs 2000; 17 (1):32-42.

[33] Mack M, Uken R, Powers JV. People improving the community's health: community health workers as agents of change. J Health Care Poor Underserved 2006; 17 (1 Suppl):16-25.

[34] Musser-Granski J, Carrillo DF. The use of bilingual, bicultural paraprofessionals in mental health services: issues for hiring, training, and supervision. Community Ment Health J 1997; 33 (1):51-60.

[35] Forst L, Lacey S, Chen HY et al. Effectiveness of community health workers for promoting use of safety eyewear by Latino farm workers. Am J Ind Med 2004; 46 (6):607-13.

[36] Staten LK, Gregory-Mercado KY, Ranger-Moore J et al. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. J Women's Health (Larchmt) 2004; 13 (5):547-56; Staten LK, Taren DL, Howell WH et al. Validation of the Arizona activity frequency questionnaire using doubly labeled water. Med Sci Sports Exerc 2001; 33 (11):1959-67.

[37] Beckham S, Kaahaaina D, Voloch K-A et al. A community-based asthma management program:  effects on resource utilization and quality of life. Hawaii Med J 2004; 63 (4):121-6.

[38] Peterson-Sweeney K, McMullen A, Yoos HL et al. Parental perceptions of their child's asthma: management and medication use. J Pediatr Health Care 2003; 17 (3):118-25.

[39] Birkel RC, Golaszewski T, Koman III JJ et al. Findings from the horizontes acquired immune deficiency syndrome education project: the impact of indigenous outreach workers as change agents for injection drug users. Health Educ Q 1993; 20 (4):523-38 (p.526).

[40] Musser-Granski J et al. (1997).

[41] Barnes K et al. (1999).

[42] Krieger J, Collier C, Song L et al. Linking community-based blood pressure measurement to clinical care: a randomized controlled trial of outreach and tracking by community health workers. Am J Public Health 1999; 89 (6):856-61.

[43] Rogers M, Peoples-Sheps M, Suchindran C. Impact of a social support program on teenage prenatal care use and pregnancy outcomes. J Adolesc Health 1996; 19 (2):132-40.

[44] Earp JA et al. (2002).

[45] Bone LR, Mamon J, Levine DM et al. Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers. Am J Emerg Med 1989; 7 (1):16-20.

[46] Satterfield D, Burd C, Valdez L et al. The "In-Between People": participation of community health representatives in diabetes prevention and care in American Indian and Alaska Native communities. Health Promotion Practice 2002; 3 (2):166-75.

[47] Navaie-Waliser M, Martin S, Tessaro I et al. Social support and psychological functioning among high-risk mothers: the impact of the Baby Love Maternal Outreach Worker Program. Public Health Nurs 2000; 17 (4):280-91.

[48] Morisky DE, Lees NB, Sharif BA et al. Reducing disparities in hypertension control: a community-based hypertension control project (CHIP) for an ethnically diverse population. Health Promotion Practice 2002; 3 (2):264-75.

[49] Burhansstipanov L et al. (2000).

[50] History | Significant Milestones [Internet]. Window Rock (AZ): Emergency Medical Services and Department of Information Technology, Navajo Nation; 2006 [updated 2006/cited 2006 Oct 24]. Available from http://www.navajoems.navajo.org/history.htm.

[51] Mack M et al. (2006).

[52] Becker J, Kovach AC, Gronseth DL. Individual empowerment: how community health workers operationalize self-determination, self-sufficiency, and decision-making abilities of low-income mothers. J Community Psychol 2004; 32 (3):327-42.

[53] Raczynski JM, Cornell CE, Stalker VG et al. A multi-project systems approach to developing community trust and building capacity. J Public Health Management Practice 2001; 7 (2):10-20.

[54] Meister JS. Community outreach and community mobilization:  options for health at the U.S.-Mexico Border. Journal of Border Health 1997; 2 (4):32-8.

[55] Fedder DO, Chang RJ, Curry S et al. The effectiveness of a community health worker outreach program on healthcare utilization of West Baltimore City Medicaid patients with diabetes, with or without hypertension. Ethn Dis 2003; 13 (1):22-7.

[56] Rodewald LE, Szilagyi PG, Humiston SG et al. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999; 103 (1):31-8.

[57] Humphry J, Jameson LM, Beckham S. Overcoming social and cultural barriers to care for patients with diabetes. Western Journal of Medicine 1997; 167 (3):138-44.

[58] What is a Navigator [Internet]. Houston (TX): Gateway to Care; 2000 [updated 2006 Oct 19/cited 2006 Sep 29]. Available from http://www.gatewaytocare.org/what_is_a_navigator.htm.

[59] Lacey L, Tukes S, Manfredi C et al. Use of lay health educators for smoking cessation in a hard-to-reach urban community. J Community Health 1991; 16 (5):269-82.

[60] Chapter 4723-26 Community Health Workers [Internet]. Columbus (OH): Ohio Board of Nursing; 2005 [updated 2005 Feb 01/cited 2006 Sep 29]. Available from http://www.nursing.ohio.gov/Law_and_Rule.htm.

[61] Williams DM. La Promotora. Linking disenfranchised residents along the border to the U.S. health care system. Health Aff (Millwood) 2001; 20 (3):212-8; Barnes MD, Fairbanks J. Problem-based strategies promoting community transformation: implications for the community health worker model. Fam Community Health 1997; 20 (1):54-65; Mack M et al. (2006).