Community health worker training and certification programs in the United States: findings from a national survey

OBJECTIVE: To analyze trends and various approaches to professional development in selected community health worker (CHW) training and certification programs in the United States. We examined the expected outcomes and goals of different training and certification programs related to individual CHWs as well as the community they serve. METHOD: A national survey of CHW training and certification programs. Data collection was performed through personal interviews, phone interviews and focus groups. Data sources included public health officials, healthcare associations, CHW networks, community colleges, and service providers. Initial screening interviews resulted in in-depth interviews with participants in 19 states. We applied human capital theory concepts to the analysis of the rich qualitative data collected in each state. RESULTS: CHW programs in the U.S. seem to have been initiated mainly due to lack of access to healthcare services in culturally, economically, and geographically isolated communities. Three trends in CHW workforce development were identified from the results of the national survey: (1) schooling at the community college level - provides career advancement opportunities; (2) on-the-job training - improves standards of care, CHW income, and retention; and (3) certification at the state level - recognizes the work of CHWs, and facilitates Medicaid reimbursement for CHW services. CONCLUSION: Study findings present opportunities for CHW knowledge and skill improvement approaches that can be targeted at specific individual career, service agency, or community level goals. Trained and/or certified community health workers are a potential new and skilled healthcare workforce that could help improve healthcare access and utilization among underserved populations in the United States.     

The Value of Community Health Workers in Diabetes Management in Low-Income Populations: A Qualitative Study

To describe community health workers (CHWs) roles in a diabetes self-management intervention. Retrospective qualitative inductive analysis of open text home visit encounter form from Peer Support for Achieving Independence in Diabetes (Peer AID), a randomized controlled trial in which low-income individuals with poorly controlled diabetes received either CHW home visits or usual care. Following visits, CHWs completed encounter forms documenting the health goal of the visit, the self-management strategies discussed and participant concerns. 634 encounter reports were completed for the 145 intervention participants. CHW notes revealed three main obstacles to optimal disease control: gaps in diabetes knowledge and self-management skills; socioeconomic conditions; and the complexity of the healthcare system. CHWs helped participants overcome these obstacles through extensive, hands-on education, connecting participants to community resources, and assistance navigating the medical system. In addition, the CHWs offered uncomplicated accessibility and availability to their clients. CHWs can be a valuable asset for low-income patients with chronic health conditions who may require more support than what can provided in a typical primary care visit.     

‘I have a lot of faith in her’: Value of community health workers in addressing family planning in rural Ghana

ABSTRACT

In rural settings with shortages in trained health care workers, community health workers (CHWs) play an important role in the delivery of health care services. The Ghana Health Service initiated a national CHW programme in 2016 to expand health services to rural populations. This study explored the perceived role and value of CHWs in addressing family planning issues in the Amansie West district of Ghana. The study included in-depth interviews (IDIs) with 28 women in the community, ages 18–49, and 30 CHWs. Using inductive thematic analysis, IDIs were coded to explore opinions on the CHWs’ role and perceived value in the delivery of family planning. Participants explained that CHWs provided family planning as part of a healthcare package through household visits and referrals to government services. The value of CHWs in delivering family planning was seen in confidentiality, accessibility, and comfort. Participants recommended an enlarged CHW workforce with a range of commodities and programmatic support. The findings suggest CHWs play an important role in promoting family planning, by serving as a bridge between the community and clinics. In rural communities where resources are scarce, CHWs are an invaluable part of the broader healthcare system.     

Infant health effects of a nurse–community health worker home visitation programme: a randomized controlled trial

Background Home visiting is supported as a way to improve child health and development. Home visiting has been usually provided by nurses or community health workers (CHWs). Few studies compared the child health advantages of a nurse–CHW team approach over nurse prenatal and postnatal home visiting. Methods A randomized trial was conducted with Medicaid‐insured pregnant women in Kent County, Michigan. Pregnant women were assigned to a team intervention including nurse–CHW home visitation, or standard community care (CC) including nurse home visitation. Morbidity was assessed in 530 infants over their first 12 months of life from medical claims and reported by the mother. Results There were no differences in overall child health between the nurse–CHW intervention and the CC arm over the first year of life. There were fewer mother‐reported asthma/wheezing/croup diagnostics in the team intervention group among infants whose mothers have low psychosocial resources (13% vs. 27%, P = 0.01; adjusted OR = 0.4, P = 0.01). There were no differences in diagnosed asthma/wheezing/croup documented by medical claims. There were no differences in immunizations, hospitalizations and ear infections. Conclusions There was no strong evidence that infant health was improved by the addition of CHWs to a programme of CC that included nurse home visitation. Targeting such interventions at common health problems of infancy and childhood or at diagnosed chronic conditions may prove more successful.     

Identifying the Core Elements of Effective Community Health Worker Programs: A Research Agenda

Community health workers (CHWs) are increasingly being incorporated into health programs because they are assumed to effectively deliver health messages in a culturally relevant manner to disenfranchised communities.Nevertheless, the role of CHWs—who they are, what they do, and how they do it—is tremendously varied. This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs, and translating research into practice.We discuss some of these challenges and provide examples from our experience working with CHWs. We call for future research to identify the “core elements” of effective CHW programs that improve the health and well-being of disenfranchised communities.THERE SEEMS TO BE A CONsensus: Community health workers (CHWs) are a good idea. They are a cost-effective way to promote health and provide some health care services to disenfranchised communities. Furthermore, because most CHWs are members of the communities within which they work, they are assumed to deliver health messages in a culturally relevant manner.1–4 Systematic literature reviews of CHW programs worldwide have provided evidence of their effectiveness for certain behaviors and disease categories, but evidence is still insufficient to justify general recommendations for policy and practice.4–8Although community educators and healers have existed worldwide for centuries, CHWs, defined as laypersons who serve as liaisons between members of their communities and health care providers and services, have played a formal role in health care since the 1940s.6,9 Over time, health program planners’ efforts to collaborate with CHWs have waxed and waned because of factors such as economic need or health care labor shortages.9,10 Yet, in the United States since the 1980s, health program planners have increasingly collaborated with CHWs to deliver various types of health promotion programs.9,11 With this increase, it has become undoubtedly clear that the role of CHWs today—who they are, what they do, and how they do it—is tremendously varied.10 This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs and to translate that research and evidence into practice.To ensure that planners integrate CHWs into programs effectively, researchers must seek clarity about the following issues: What problems arise because of the variability surrounding who CHWs are and what they do? How can we evaluate CHW programs to better document their effectiveness? And, ultimately, how can we elucidate the core elements of CHW programs so that effective programs can be adopted and implemented in other settings? We explore these issues and provide some examples from our firsthand experience as academic researchers who collaborate primarily with promotores (CHWs for Latino populations).Community health workers are described by using several different terms, including lay health advisors, patient navigators, promotores, outreach workers, peer leaders, peer educators, and community health advocates. The diversity of names reflects the different types of roles, or even opposing roles, CHWs are expected to play. For example, the word “lay” in “lay health advisors” suggests that CHWs are not “professionals,” nor have they acquired “expert” knowledge that would set them apart from an ordinary person. The term “patient navigators” implies that the CHWs are embedded within a health care system to the extent that they can help link patients to appropriate care. “Peer leaders” suggests that there is a commonality between the CHWs and their clients, and that they have some leadership characteristics that motivate community members to model or adhere to their recommendations. The term “health advocate” implies that CHWs play an activist role within their community and that their work is related to the larger struggle for social justice for disenfranchised communities. The differences in roles implied by these terms are more than simple semantics; they imply skills and training that would likely vary considerably.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

Impact of dropout of female volunteer community health workers: an exploration in Dhaka urban slums

ABSTRACT: BACKGROUND: Volunteer Community Health Workers (CHWs) are a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, uses female CHWs as core workers in its community-based health programs since 1977. After 25 years of implementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through a community-based maternal health intervention. However, BRAC experiences high dropout rates among CHWs suggesting a need to better understand the impact of their dropout which will help to reduce dropout and increase program sustainability. The main objective of the study is to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, it estimates cost of possible strategies to reduce dropout and compares whether they are more or less than the cost borne by BRAC and the community. METHODS: The study uses 'ingredient approach' to estimate the cost of recruiting and training of CHWs and so-called 'friction cost approach' to estimate the cost of replacement of CHWs after adapting. Finally, forgone services in the community due to CHW dropout are estimated applying the concept of friction period. RESULTS: In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if a CHW participated, a three-week basic training, a one-day refresher training, one incentive day and worked for a month in the community after recruitment. One month absence of a CHW with standard average performance in the community means substantial forgone health services like health education, antenatal visits, deliveries, referrals of complicated cases, and distribution of drugs and health commodities. However, with an additional investment of US$ 121 yearly per CHW BRAC can save another US$ 60 invested for ad-hoc CHWs plus forgone services in the community. CONCLUSION: Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immense both in financial term and forgone services. High cost of dropout makes the program less sustainable. However, simple and financially competitive strategies could improve the sustainability of the program.     

Community health workers "101" for primary care providers and other stakeholders in health care systems

Today's ambulatory care providers face numerous challenges as they try to practice efficient, patient-centered medicine. This article explains how community health workers (CHWs) can be engaged to address many patient- and system-related barriers currently experienced in ambulatory care practices. Community health workers are frontline public health workers who serve as a trusted bridge between community members and health care providers. Among their varied roles, CHWs can educate and support patients in managing their risk factors and diseases and link these patients to needed resources. As shown in this overview (CHW 101), including CHWs as members of multidisciplinary care teams has the potential to strengthen both current and emerging models of health care delivery.     

Integrating community health workers into a community hearing health collaborative to understand the social determinants of health in children with hearing loss

BackgroundChildren with hearing loss (HL) require coordination of care to navigate medical and social services. Strong evidence supports the role of community health workers (CHWs) to identify and address social barriers.ObjectiveThe goal of this study was to evaluate the impact of integrating CHWs into the medical teams of children with HL and identify the social needs associated with their caregivers at a large urban hospital center.MethodsA retrospective chart review was conducted for 30 children with HL whose caregivers enrolled in a CHW program between August 1, 2017 and December 31, 2019. Baseline demographic data were collected, including social circumstances such as food and housing insecurity, status of social security supplemental income (SSI), and need for referral to early intervention (EI) or preschool/school services. Caregivers were assessed for confidence in self-management; baseline distress level was measured via a distress thermometer.ResultsOf the 30 charts reviewed, 93% demonstrated social needs including food insecurity (24%) and educational service needs (45%). Eighty-seven percent of caregivers reported a sense of control over the child's condition, yet 73% reported a stress level of four or greater on the distress thermometer scale. At 3 months follow-up, 70% of patients completed referrals; a significant number of patients had obtained hearing aids and cochlear implants compared to baseline (p = 0.017).ConclusionsCaregivers of children with HL face multiple social obstacles, including difficulties connecting to educational and financial resources. CHWs are instrumental in identifying social needs and connecting caregivers to services.     

Examining the Macrosystem Level of Influence on Community Health Worker Effectiveness in the State of Nebraska: A Qualitative Approach

Community health workers (CHWs) serve as the linkage between community and providers and are stakeholders for bridging services to the public. However, integration of CHWs into health care organizations is often lacking. This study explored macrosystem level barriers faced by CHWs and their ability to do their jobs effectively. Using qualitative interviews from CHWs (n?=?28) in Nebraska, we used an abductive approach to derive the following themes: (1) CHWs and client macrosystem barriers, (2) CHW workforce supports, and (3) macrosystem solutions for CHW workforce sustainability. Study results also found various macrosystem barriers affecting CHW workforces including immigration policies, insurance policies, funding sources, supervisor support, and obstacles for health seeking of clients. Moreover, through the lens of CHWs, results revealed the need to provide and advocate for solutions that prioritize the needs of CHWs as they continue to fill a crucial gap in community healthcare systems.

     

Building a Consensus on Community Health Workers’ Scope of Practice: Lessons From New York

Objectives. We evaluated efforts in New York to build a consensus between community health workers (CHWs) and employers on CHWs’ scope of practice, training standards, and certification procedures.Methods. We conducted multiple-choice surveys in 2008 and 2010 with 226 CHWs and 44 employers. We compared CHWs’ and employers’ recommendations regarding 28 scope of practice elements. The participatory ranking method was used to identify consensus scope of practice recommendations.Results. There was consensus on 5 scope of practice elements: outreach and community organizing, case management and care coordination, home visits, health education and coaching, and system navigation. For each element, 3 to 4 essential skills were identified, giving a total of 27 skills. These included all skills recommended in national CHW studies, along with 3 unique to New York: computer skills, participatory research methods, and time management.Conclusions. CHWs and employers in New York were in consensus on CHWs’ scope of practice on virtually all of the detailed core competency skills. The CHW scope of practice recommendations of these groups can help other states refine their scope of practice elements.Under the Affordable Care Act (Pub L No. 111-148), the landmark health care reform legislation signed into law by President Obama, millions of Americans will have access to quality, affordable health care. However, cultural, language, or other vulnerabilities can prevent millions of people from benefiting from this care. Community health workers (CHWs) are in a unique position to help. CHWs can break down barriers so that people can receive the health care services they need, and they can assist them in benefiting fully from those services.1 A growing number of studies have shown that CHWs can help ensure equitable access to care, decrease health care costs, and improve outcomes, including self-management of chronic diseases such as asthma or diabetes.1–13 The valuable role CHWs can play is clear, and many groups are now working to outline the details of their roles across a spectrum of conditions and communities.In addition to the critical questions of how and for whom CHWs can most effectively provide these services, attention needs to be paid to ensuring that the CHW workforce is structured to respond to this demand. Surveys of the CHW workforce have concluded that although there may be as many as 120 000 CHWs in the United States today,14 there are no national standards defining what a CHW does as a member of the health care team or what criteria might be used to qualify CHWs for reimbursement through sustainable funding such as Medicaid. National organizations such as the American Association of Community Health Workers and the American Public Health Association (APHA) have been working to support the development of CHW workforce standards,15 and the Bureau of Labor Statistics has established a standard occupational code for CHWs.16 The APHA CHW Section’s definition of a CHW is increasingly recognized as the nationally accepted definition:

Community Health Worker (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.15

Setting workforce standards begins with the establishment of a scope of practice, the roles and tasks performed by practitioners, along with the usual education and competencies required for that practice. In 1998 the National Community Health Advisor Study (NCHAS), a milestone review of CHW roles and activities, listed 7 basic roles, 8 core skills or competencies, and 7 additional qualities supporting accomplishment of these CHW roles17; however, these elements need to be reviewed and tailored as appropriate to ensure that they capture context-specific roles. Establishment of a scope of practice for credentialing is a state responsibility, and 17 states are now in the process of establishing standards for CHWs.1,18,19As is the case with members of any other profession establishing standards for itself, CHWs should lead in identifying appropriate scope of practice roles, and this is the approach that has been adopted in New York.1 In 2005, the Mailman School of Public Health and the CHW Network of NYC began an academic–community partnership to elicit CHWs’ views on establishing practice and training standards. We learned that although CHWs felt they were recruited for qualities such as dedication to the community and trust, often employers valued a wholly different skill set that included informal counseling, teaching, and promotion of behavior change. CHWs saw themselves in terms of “who” they were in the community, whereas employers viewed them according to “what” they could do.20 We concluded that if there is to be agreement on scope of practice, it is critical that each group, CHWs and their employers, agree on both the “who” and “what” questions.To develop a consensus scope of practice, we set out to determine CHWs’ perceptions of the most appropriate set of roles and skills for their profession, as well as potential employers’ perceptions of those roles and skills. We used a community-based participatory research approach to simultaneously obtain input from CHWs and employers on these topics that could be used in achieving a consensus, and here we report on the recommendations derived from this multiyear process.     

The work of community health workers in major cities in Brazil: mediation, community action, and health care

This paper examines the role of community health workers (CHWs) and discusses the challenges in performing their multiple functions as: mediators linking the community and health services, community organizers, and care providers. A survey of CHWs was conducted in four towns in Brazil. The results indicate that during their home visits and community actions, the CHW perform educational and care activities for priority groups. Some CHWs work in health centers, where their functions include care management for chronic patients. The results indicate gaps in the work actually done, mainly as regards the expectation that CHWs would play a more political role, mediating between the communities and public policies, especially health policy. The CHWs in Brazil are general-purpose health personnel with a hybrid role that oscillates from technical to political profile.     

The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis

There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.     

Exploring the roles and factors influencing community health workers’ performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa

As primary providers of preventive and curative community case management services in low‐ and middle‐income countries (LMICs), community health workers (CHWs) have emerged as a formalised part of the health system (HS). However, discourses on their practices as formalised cadres of the HS are limited. Therefore, we examined their role in care, referral (to clinics) and rehabilitation of severe acute malnutrition (SAM) cases. Focusing on SAM was essential since it is a global public health problem associated with 30% of all South Africa's (SA's) child deaths in 2015. Guided by a policy analysis framework, a qualitative case study was conducted in two rural subdistricts of North West province. From April to August 2016, data collected from CHW's training manuals and guideline reviews, 20 patient record reviews and 15 in‐depth interviews with four CHW leaders and 11 CHWs. Using thematic content analysis which was guided by the Walt and Gilson policy triangle, data was manually analysed to derive emerging themes on case management and administrative structures. The study found that although CHWs were responsible for identifying, referring, and rehabilitating SAM cases, they neglected curative roles of stabilisation before referral and treatment of uncomplicated cases. Such limitations resulted from restrictive CHW policies, inadequate training, lack of supportive supervision and essential resources. Concurrently, the CHW program was based on weak operational and administrative structures which challenged CHWs practices. Poor curative components and weak operational structures in this context compromised the use of CHWs in LMICs to strengthen primary healthcare. If CHWs are to contribute to Sustainable Development Goal (SDG) 3 by reducing SAM mortality, strategies on community management of acute malnutrition coupled with thorough training, supportive supervision, firm operational structures, adequate resources and providers’ motivation should be adopted by governments.     

Effectiveness of community health workers in Brazil: a systematic review

The objective of this study is to assess the effectiveness of community health workers (CHWs) in Brazil. This systematic review included all studies that sought to assess interventions involving CHWs. Despite the low quality of evidence for most outcomes, analysis of the 23 publications included often found benefit for CHW intervention, best documented for frequency of child weighing, prevalence of breast-feeding, and delayed introduction of bottle-feeding. These findings and the current major role CHWs play in Brazil suggest that clarifying the benefit of CHW actions across a broad range of health care interventions should be a major research priority.     

Patterns of Enrollment Churn in Medicaid Expansion,Subsequent Insurance Coverage,and Access to Care: A Longitudinal Study

Understand enrollment patterns in Medicaid expansion and how churn and disenrollment affect access to care. We conducted telephone surveys with a cohort of Medicaid expansion enrollees at 3 time points in 2016, 2017, and 2018 (N = 2,608, RR = 89.4%). Surveys measured health, access to care, and insurance status. Respondents who had no HMP/Medicaid enrollment for > 3 consecutive months but re-enrolled (according to state records) were categorized as “churned off/on”; those who had disenrolled from HMP/Medicaid for > 6 months were categorized as “off for > 6 months”; the remainder were categorized as “stayed on.” We used Pearson chi-square tests to compare groups and mixed models with year as a fixed effect to assess changes over time, incorporating weights adjusting for sample design and nonresponse. HMP beneficiaries with ≥ 12 months of HMP coverage in 2016. As of 2018, 74.2% stayed on HMP/Medicaid, 9.8% churned off/on, and 16.0% were off for > 6 months. Going off HMP/Medicaid for > 6 months was more likely for men than women (17.7% vs. 14.6%), those age 19-34 and 35-50 compared to 51-64 (17.1%, 17.0%, and 13.3%), those who were married/partnered compared to those who were not (18.6% vs. 14.3%), those with compared to without a chronic condition (18.9% vs. 14.3%), and those without compared to with a mental health condition or substance use disorder (22.1% vs. 12.6%) (all, P < .05). Employed respondents in 2017 or 2018 were more likely than those unemployed to have gone off HMP/Medicaid for > 6 months (21.7% vs. 5.2%, P < .001)). Employed respondents (11.1% vs. 7.0% not employed), black respondents (14.7% vs. 7.1% white), men (11.7% vs. 7.9% women), those in the youngest age group (14.4% vs. 7.5% for 35-50 and 5.7% 51-64), and those not married/partnered (11.3% vs. 7.3% married/partnered) were all more likely to churn off/on (all, P < .05). More than half (58.9%) of respondents who were off for > 6 months had a period of uninsurance in 2017 or 2018. Respondents who were off > 6 months were less likely than those who stayed on to report having a regular source of care (84.6% vs 93.9%), more likely to report forgone health care for financial reasons (17.0% vs. 3.2%) and more likely to report problems paying medical bills (32.6% vs. 17.5%). Those who churned off/on were also less likely than those who stayed on to report having a regular source of care (83.6% vs. 93.9%) more likely to report forgone health care for financial reasons (7.5% vs. 3.2%) and more likely to report problems paying medical bills (40.4% vs. 17.5%). In a longitudinal study of Medicaid expansion, approximately a quarter of enrollees had either churned off and on HMP/Medicaid or had extended disenrollment over a three-year period. Those who had experienced churn or extended disenrollment were more likely to report forgone health care, not having a regular source of care, and problems paying medical bills. Many Medicaid enrollees who experience churn or disenrollment have difficulty maintaining health insurance and face financial obstacles to care. Michigan Department of Health and Human Services.