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Employers hiring community health workers
have been looking for individuals with
some formal education, specific qualities,
and certain skills. Also, while employers
have provided post-employment training
for general education and specific competencies,
they have not always offered opportunities
for a career as a CHW.
Requirements at
Hiring
Communication skills, combined with the
ability to create interpersonal relationships
and maintain confidentiality, were considered
by most organizations as essential attributes
for a job as a CHW. Organizational skills,
such as the ability to set goals, develop
action plans, and keep records, were highly
regarded as well. Also, almost half of
the respondents to the CHW National Employer
Inventory (CHW/NEI) placed value on bilingual
abilities, the ability to coordinate service
referrals, and adeptness in promoting
and advocating family and community wellness
(Figure 4.1).
 [D]
Source: CHW National Employer Inventory
(CHW/NEI) (2006), N=570
Language skills
Employers reported that the languages
most often used by CHWs to communicate
with clients were English and Spanish
(87 and 70 percent of the respondents,
respectively). Less than 10 percent of
the employers reported the use of French,
Vietnamese, and Chinese. Few (6.4 percent)
reported the use of sign language and
knowledge of tribal languages (3.8 percent).
Most of the employers surveyed and interviewed
did not offer language training[1]
and selected CHWs on the basis of their
existing language competence.
Cultural competence
Cultural competence was defined in this
study as "the ability of understanding
and working within the context of the
culture of the community being served."
This definition was easily understood
and agreed upon in field testing and by
employers interviewed in the four States
selected for further study. However, responses
were mixed as to whether cultural competence
required that the CHW be a resident of
the area being served.[2]
The issue is related to the degree of
diversity of the population. In New York
City alone, out of 2,217 Census tracts,
those defined as including highly diverse
cultures increased from 70 in 1970 to
220 in 2000.[3] While
reliance on one's culture of origin has
been effective in narrow-focus, grant-funded
projects targeting persons of similar
ethnic or cultural heritage, broader-purpose
community or clinic-based programs require
that CHWs interact effectively with persons
of different cultural backgrounds. Also,
relying on CHWs from different communities
might be necessary in smaller areas where
candidates with the required CHW skills
may be scarce.[4] In
conclusion, while CHWs were generally
hired for their "insider" status
and their understanding of underserved
populations,[5] employers
were ambivalent about the importance of
CHWs sharing place of residence with the
clients they assisted.
Education
About half of employers responding to
the "CHW education" component
of the National Employer Inventory (N=487)
questionnaire had educational or training
requirements for CHW positions. Twenty-one
percent mentioned that at least a high
school diploma or GED was expected. A
Bachelor's Degree was a prerequisite to
employment in 32 percent of the organizations.
Training During
Employment
Most employers required post-hire training
of CHW personnel.[6]
Two types of training were commonly offered.
One was aimed at reinforcing or standardizing
the level of competence of the CHW personnel
in the skills required at the time of
hiring[7] and the other
focused on the acquisition of competencies
needed for specific programs.[8]
The degree to which employer-based training
emphasized enhancing the generic skills
of CHWs, versus developing special competencies,
varied.[9]
Instruction to reinforce CHW cultural
awareness, interpersonal communication,
and client advocacy was offered by 80,
70, and 59 percent of respondents, respectively
(N=518). Training in being a CHW (60 percent)
and in leadership skills (38 percent)
indicated that health organizations recognized
a distinctive CHW role in health service
delivery. Many employers required the
acquisition of special competencies for
addressing specific health issues and
diseases (79 and 64 percent) such as asthma,[10]
cardiovascular disease (CVD),[11]
genetic screening and services,[12]
or colorectal cancer.[13]
Also, training was required in understanding
medical and social services (55 and 73
percent), coordinating access to services,
home visiting and patient "navigation"
(53, 47, and 41 percent), providing health
education and counseling (59 percent),
and administering first aid and CPR (40
percent).
Training was administered either as continuing
education (68 percent) with classroom
instruction (32 percent) or through mentoring
(47 percent) and on-site technical assistance
(43 percent). The length of training reported
ranged from nine to 100 hours.[14]
A recent initiative, the Community Health
Worker National Education Collaborative[15]
(CHW-NEC) funded by the U.S. Department
of Education, has convened 21 institutions
of higher education to arrive at a consensus
on a standard curriculum for entry-level
preparation of CHWs based on a "core
basic-competency" definition for
this workforce. The project is scheduled
for completion in September 2007.
Credentialing
Texas was the first State to adopt legislation
governing the utilization of CHWs (1999).
It was followed by Ohio in 2003, and other
States have been considering it.[16]
Texas
House Bill 1864, enacted by the 76th
Texas Legislature in May, 1999, directed
the Texas Department of Health (TDH),
now the Texas Department of State Health
Services (TDSHS),[17]
to "establish a temporary committee
for studying certain issues related to
the development of outreach and education
programs for promotoras or community
health workers and that will advise the
Texas Department of Health, the governor,
and the legislature regarding its findings."
In 2001, a system of credentialing was
implemented. The program was to be voluntary
for promotores(as)/CHWs[18]
who do not receive compensation for their
services and mandatory for those who are
financially compensated for the services
they provide.
Credentialing was based on eight areas
of "core competencies" identified
in the 1998 National Community Health
Advisor Study[19] and
consisting of communication skills, interpersonal
skills, service coordination skills, capacity-building
skills, advocacy skills, teaching skills,
organizational skills, and a knowledge
base on specific health issues.
Applicants for the Certified Community
Health Worker credential in Texas must
either show successful completion of an
approved training program or document
equivalent experience.[20]
Training programs must include at least
20 clock hours of instruction in each
of the eight competency areas. Renewals
are biennial and require 20 hours of continuing
education. There is no fee for either
the original application or for renewal.
Senate Bill 751, enacted in May 2001,
called for the Texas Health and Human
Services Commission to require health
and human services agencies to use certified
CHWs/promotores(as), "to the
extent possible," in performing health
outreach and education programs for recipients
of medical assistance.
Ohio
The Ohio certification program began
in 2003 and operated under authority of
Chapter 4723-26 of the Ohio Revised Code,
the Nursing Practices Act.[21]
The credential is called a "certificate
to practice" and is awarded after
completion of an approved training program.
The Ohio provision allowing documentation
of experience as a substitute for training
expired in 2005. Ohio provided for reciprocity
through certification by "endorsement"
for CHWs holding similar credentials from
other States. Renewals are biennial and
require 15 hours of continuing education
and a $35 fee.
The Ohio program's rules provided for
delegation of some nursing tasks from
an RN to a CHW but included the limitation
that the nurse may not supervise more
than five CHWs at one time.[22]
Approved training programs must consist
of at least 100 hours of didactic instruction
and 130 hours of clinical instruction,
which may include community-based fieldwork
in a setting where CHWs commonly work.
"Nursing task" skills must be
taught by an RN. The rules indicated the
intent that CHWs be able to apply credit
hours from CHW training programs to other
health career-related education.[23]
As of September, 2006, there were three
accredited certification training programs
for CHWs.[24]
Other State Initiatives
In 1994, the Indiana Medicaid Program
authorized specially trained and supervised
CHWs to make reimbursable home visits
to high-risk pregnant women. The Indiana
CHW certification program was designed
to be used only as part of this program.
The State health department created its
own curriculum and certification was awarded
on completion of an approved training
program following that curriculum. Trainers
were required to be State-certified "care
coordinators" (RNs).[25]
Alaska created another certification
program limited to one health service.
The Community Health Aide/Practitioner
(CHA/P) and Dental Health Aide/Practitioner
(DHA/P) programs provide basic care in
remote villages under medical and dental
supervision, including control of certain
prescription drugs under standing physician
orders. Since the duties of CHA/Ps and
DHA/Ps included more direct clinical care
activities than those of other CHWs, the
required training was more extensive and
clinical in nature, covering 520 hours
of instruction.
Career Opportunities
Generally, the occupation of CHW has
not been viewed as a career. The reasons
have been short-term and unstable employment,
generally low wages, lack of occupational
identity, lack of recognition by other
professionals, and the fact that CHWs
have not been fully integrated into the
U.S. health workforce.[26]
In a survey sponsored by the Massachusetts
Department of Public Health, 76 percent
of CHWs perceived that the only possible
advancement available to them consisted
of building skills and increasing their
levels of responsibility within their
current positions. Only 28 percent reported
opportunities for promotion despite the
fact that 73 percent of CHW supervisors
were former CHWs.[27]
CHW credentialing has brought greater
emphasis on CHW career patterns, but little
has been published on this topic. Some
CHW positions have been considered by
some to be stepping-stones to other health
and social service careers. One California
program considered part of its mission
to encourage successful CHWs to move on
to other employment, thereby opening these
positions for other community residents.[28]
The only effort targeted toward CHW career
advancement was noted in New Jersey, where
the AHEC Program received HRSA funding
in 2005 to create (among other objectives)
a CHW career development initiative in
the State. The initiative would establish
model standards for career development
as well as a system of supports for CHWs
who wished to pursue education and training
to enter other health-related occupations.[29]
In California, some local health departments
have utilized CHWs in unionized positions,
working in standardized job descriptions
with up to four levels of seniority.[30]
Three of the Texas employers interviewed
had multi-level CHW career ladders, but
none of the CHWs interviewed in the four
selected States had CHW-specific career
ladders within the organizations for which
they were working.
[1]
CHW National Employer Inventory (CHW/NEI)
(2006); CHW National Workforce Study Interviews
(CHW/NWSI) (2006).
[2] CHW/NWSI (2006).
[3] Berger J. Brooklyn's
Technicolor Dream Quilt. New York Times
2005 May 29:33.
[4] Health Resources
and Services Administration. Impact of
community health workers on access, use
of services, and patient knowledge and
behavior. Bureau of Primary Health Care,
Health Resources and Services Administration,
U.S. Department of Health and Human Services
1998.
[5] Love MB, Legion V,
Shim JK et al. CHWs get credit: a 10-year
history of the first college-credit certificate
for community health workers in the United
States. Health Promotion Practice 2004;
5 (4):418-28.
[6] CHW/NWSI (2006);
CHW/NEI (2006).
[7] CHW/NWSI (2006).
[8] 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; Rosenthal EL, Wiggins N, Brownstein
JN et al. The Final Report of the National
Community Health Advisor Study. Tucson
(AZ): University of Arizona, 1998.
[9] Ireys HT, Chernoff
R, DeVet KA et al. Maternal outcomes of
a randomized controlled trial of a community-based
support program for families of children
with chronic illnesses. Arch Pediatr Adolesc
Med 2001; 155 (7):771-7.
[10] 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.
[11] 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.
[12] Bridge M, Iden
S, Cunniff C et al. Improving access to
and utilization of genetic services in
Arizona's Hispanic population. Community
Genetics 1998; 1 (3):166-8.
[13] Campbell MK, James
A, Hudson MA et al. Improving multiple
behaviors for colorectal cancer prevention
among African American church members.
Health Psychol 2004; 23 (5):492-502.
[14] Campbell MK et
al. (2004); DePue JD, Wells BL, Lasater
TM et al. Volunteers as providers of heart
health programs in churches: a report
on implementation. Am J Health Promot
1990; 4 (5):361-6; Iryes HT et al. (2001);
Lam TK, McPhee SJ, Mock J et al. Encouraging
Vietnamese-American women to obtain Pap
tests through lay health worker outreach
and media education. J Gen Intern Med
2003; 18 (7):516-24; Quinn MT, McNabb
WL. Training lay health educators to conduct
a church-based weight-loss program for
African American women. Diabetes Educ
2001; 27 (2):231-8; 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;
Love MB et al. (1992).
[15] This project is
still in progress.
[16] Arizona, California,
Kentucky, Massachusetts, Nevada, and New
Mexico were listed as those considering
certification in May ML, Kash B, Contreras
R. Southwest Rural Health Research Center:
Community Health Worker (CHW) Certification
and Training - A National Survey of Regionally
and State-based Programs. Office of Rural
Health Policy, Health Services and Resources
Administration, U.S. Department of Health
and Human Services 2005. No additional
information was provided as to how each
of these States were considering certification.
[17] TDH became the
Texas Department of State Health Services
(TDSHS) in 2004.
[18] Defined in Chapter
1.
[19] Rosenthal EL et
al. (1998).
[20] Required experience
includes 1,000 hours of activities using
the core competencies in a 12-month period
ending no later than January 2005.
[21] See 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.
[22] ORC §4723-26-08
and -09
[23] ORC §4723-26-10
and ORC §4723-26-12
[24] Approved Community
Health Worker Training Programs in Ohio
[Internet]. Columbus (OH): Ohio Board
of Nursing; 2006 [updated 2006 May/cited
2006 Oct 02]. Available from http://www.nursing.ohio.gov/CommunityHealthWorkers.htm.
[25] May ML et al. (2005).
[26] Love MB et al.
(2004).
[27] 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.
[28] Rush CH. Telephone
Conversation with: Ellen Pais (Urban Education
Partnership). 2006 February 10.
[29] HRSA Grant number
U77HP03629 to the University of Medicine
and Dentistry of New Jersey, School of
Osteopathic Medicine, effective September
1, 2005.
[30] E.g., City and
County of San Francisco. 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.
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