Community health workers (CHW) are also known as community health advocates, lay health educators, community health representatives, peer health promoters, community health outreach workers, and in Spanish, promotores de salud. They are “community members who work almost exclusively in community settings. They serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate health care."
—Witmer 1995, p. 1055

2. What are some typical duties of CHWs?

They strengthen already existing community network ties.
They live in the communities in which they work, understand what is meaningful to those communities, and communicate in the language of the people.
They recognize and incorporate cultural buffers.
They build partnerships with formal health care delivery systems to connect people with the services they need.
They educate providers about the community’s health needs and the cultural relevancy of interventions.
They can feasibly help reduce health care and personal costs as they help improve outcomes for community members.

3. What are core services of CHWs that were identified by the National Community Health Advisor Study, conducted by the University of Arizona and the Annie E. Casey Foundation (published in 1998)?

Bridge cultural mediation between communities and the health care system.
Provide culturally appropriate and accessible health education and information, often by using popular education methods.
Assure that people get the services they need.
Provide informal counseling and social support.
Advocate for individuals and communities within the health and social service systems.
Provide direct services, such as basic first aid, and administer health screening tests.
Build individual and community capacity.

4. Is there a database of CHW programs?

The Centers for Disease Control and Prevention provided leadership in documenting and acknowledging the role of CHWs, establishing the first national database in 1993. It includes CHW programs, training centers, and journal articles on models, research, and practice information. The Combined Health Information Database (CHID) has documented more than 200 programs, representing about 10,000 CHWs. In 2002, the CHW programs supported by the Bureau of Primary Health Care in the Health Resources and Services Administration (HRSA) were added to the database.

In May 2003, the Center for Sustainable Health Outreach* began a project to collect information about U.S. CHW programs. The center collaborated with the University of Southern Mississippi/Hattiesburg and the Harrison Institute for Public Law of Georgetown University, Washington, DC. They will soon have a form on their Web site to submit information about CHW programs that will be included in their database and in the CDC CHID. Project directors can also submit information via mail, fax, or telephone interview. For more information, E-mail Paul.Philpot@usm.edu or call 601-266-6709, fax 601-266-6262, or write USM CSHO, Attn: Paul Philpot, Box 10015, Hattiesburg, MS 39406-0015.

5. Why are CHWs important regarding diabetes?

The epidemic of type 2 diabetes is exacting a staggering toll on individuals, families, and communities in the United States and, increasingly, around the world. In the United States, the burden is disproportionately borne by American Indian and Alaska Natives, African Americans, Hispanic or Latino Americans, and Asian and Pacific Islanders.

Many health programs are turning to CHWs for their unique ability to serve as “bridges” between community members and health care services (Satterfield, Burd, Valdez, Hosey, & Eagle Shield 2001). Recognition of the roles, skills, and contributions of CHWs; support for programs, including stable funding, technical assistance, and evaluation; and continuing education are needed to respectfully and effectively integrate these workers into the health care delivery system (Witmer 1995).

6. What are some examples of CDC initiatives involving CHWs?

The U.S.-Mexico Border Diabetes Prevention and Control Project’s Intervention Phase 2 involves promotores de salud in a diabetes health promotion intervention at the family unit level. This project has been guided by the recommendations of the National Hispanic/Latino Diabetes Initiative for Action Recommendations report (1997).
Evaluation of a diabetes curriculum developed by Midwest Latino Research and Training Center, in collaboration with CDC, demonstrated improvement of glucose control among Hispanic and Latino persons living with diabetes. A CHW specially trained in diabetes care and education taught the curriculum and provided social support to participants throughout the 24-month evaluation period.
Project DIRECT has used community exercise leaders (DIRECT is an acronym for Diabetes Intervention Reaching and Educating communities Together).
The Native Diabetes Wellness Program’s activities in developing a directory of CHW resources and a video illustrating CHWs in action.

7. What evidence shows the effectiveness of CHWs in diabetes education and self-care?

The use of CHWs in health intervention programs has been associated with improved health care access, prenatal care, pregnancy and birth outcomes, client health status, health- and screening-related behaviors, as well as reduced health care costs (Brownstein 1998). A growing body of evidence documents the effectiveness of CHWs in diabetes care and education efforts. Some examples follow:

A 6-month self-management program for patients with chronic disease who worked with lay health instructors resulted in improved health behaviors, improved health status, and fewer hospitalizations compared with usual care (Lorig et al. 1999).
44 clients with diabetes in St. Louis, Missouri, who accepted a home health aide to support their self-care for 18 months showed improved glycemic control and attendance at eye and diabetes clinic visits, and fewer emergency room visits compared with a control group (Hopper, Miller, Birge, & Swift 1984).
Hispanic clients who were assigned to a CHW intervention group were more likely than those who were not to complete their diabetes education programs (Corkery et al. 1997; Brown & Harris 1995).
More than 100 Spanish-speaking persons using peer educators demonstrated improved diabetes education and self-care (Lorig & Gonzalez 2001).

8. What are CDC’s goals and recommendations for CHWs?

Based on a review of the literature and on CDC’s experience with strategies involving CHWs, the internal workgroup identified these goals and recommendations:

Build stronger support for CHWs that is integrated within diabetes health care teams and programs
- To serve as bridges between the health care system and people living with and at risk for diabetes; and
- To provide support for diabetes control programs, community-based organizations, and other agencies instrumental in establishing these links.
Create educational opportunities, including ongoing technical assistance for CHWs with diabetes training designed to help them
- To promote actions that enable community members to access care that meets standard recommendations for diabetes care and prevention; for example, receiving annual eye and foot exams and regular A1C testing;
- To develop and communicate culturally and linguistically appropriate messages on diabetes self-care and community action;
- To provide social support to community members as they adapt their lifestyles, through counseling and motivational interviewing; and
- To mobilize their communities for social action to address diabetes on several levels; for example, in social and political situations.
Value the contribution CHWs can make in educating health care providers about a community’s needs, the relevance of interventions, and cultural competence.
Promote sustainability of CHW models by means that include the following:
- Develop public health policy, appropriate management practices, and other innovations, such as policies and recommendations, that recognize and support the role of CHWs; and
- Share evidence of successful programs in various communication channels; for example, in local newspapers and radio stations, state and national conferences, and peer-reviewed publications.
Apply the seven core services provided by CHWs (identified through the National Community Health Advisor study) and their related skills and qualities to guide development of CHW-related programs.
Support evaluation of CHW models related to diabetes prevention and care.
Support CDC’s National Center for Chronic Disease Prevention and Health Promotion to increase the engagement of CHWs in theory and practice for strategies to help eliminate health disparities, and make possible the means
- To develop and maintain a CHW database;
- To identify and share common “best processes” of CHW programs;
- To create educational and networking opportunities for CHWs; and
- To provide assistance with CHW-involved community-based evaluations.

* Links to non-Federal organizations are provided solely as a service to our users. Links do not constitute an endorsement of any organization by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at this link.

References

Brown SA, Harris CL. (1995). A community-based, culturally sensitive education and group-support intervention for Mexican Americans with non-insulin-dependent diabetes: a pilot study of efficacy. Diabetes Educ, 21, 203-210.

Brownstein, JN(1998). The challenge of evaluating CHA services. In: Rosenthtal EL, Wiggins N., Brownstein JN, Meister J, Rael R., de Zapien, G et al., editors. Report of the National Community Health Advisor Study. Baltimore, MD: University of Arizona Press, pp. 50-74.

Corkery E, Palmer C, Foley ME, Schecter CB, Frisher L, Roman SH. (1997). Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population. Diabetes Care, 20, 254-257.

Hopper SV, Miller JP, Birge C, Swift J. (1984). A randomized study of the impact of home health aides on diabetes control and utilization patterns. Amer J Public Health 74, 600-602.

Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW Jr, Bandura A, Gonzalez VM, Laurent DD, Holman HR. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 39(11):1217-23.

Lorig, K, Sobel, DS, Stewart AL, Brown, BW, Bandura, A., Ritter P, Gonzalez VM, Laurent DD, & Holman HR. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Med Care, 37, 5-14.

Satterfield DW, Burd C, Valdez , Hosey G, Eagle Shield J. (2002). The "in-between" people: participation of community health representatives in diabetes prevention and care in American Indian and Alaskan Native communities. Health Promot Pract, 3 (2): 166-175.

Witmer A. (1995). Community health workers: integral members of the health care work force. Am J Public Health, 85, 1055-58.

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