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Community Health Worker Profiles A Study of Employment Trends

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					Community Health Worker Profiles:
A Study of Employment Trends in
          the Bay Area

        Culminating Experience
              Final Report



        Master in Public Health



           By Sahru Keiser
       San Francisco, California
           May 15th, 2006




            CE Committee:
        Mary Beth Love, PhD and
           Rick Harvey, PhD
TABLE OF CONTENTS
ABSTRACT......................................................................................................................................................................... 3
INTRODUCTION .............................................................................................................................................................. 4
LITERATURE REVIEW.................................................................................................................................................. 7
   TOPIC AREAS THAT CHWS WORK IN ................................................................................................................................ 7
   EFFECTIVENESS OF CHW PROGRAMS .............................................................................................................................. 8
   SKILLS AND COMPETENCIES OF CHWS .......................................................................................................................... 14
   ROLES, RESPONSIBILITIES AND ACTIVITIES OF CHW S .................................................................................................. 16
   FUNDING INSTABILITY FOR CHW SERVICES ................................................................................................................. 17
   GAPS IN THE LITERATURE ............................................................................................................................................... 18
   PUBLISHING IN ACADEMIC JOURNALS ........................................................................................................................... 19
GOALS & OBJECTIVES ............................................................................................................................................... 22
METHODS ........................................................................................................................................................................ 23
   EXHAUSTIVE LITERATURE REVIEW ............................................................................................................................... 23
   COMPARISON OF LABOR MARKET STUDIES .................................................................................................................... 24
   PUBLICATION PROCESS ................................................................................................................................................... 25
   CONFERENCE SUBMISSIONS ............................................................................................................................................ 27
RESULTS........................................................................................................................................................................... 27
   COMPARISON OF CHW LABOR MARKET STUDIES.......................................................................................................... 28
   PUBLICATION ................................................................................................................................................................... 34
   CONFERENCES ................................................................................................................................................................. 35
DISCUSSION .................................................................................................................................................................... 36
RECOMMENDATIONS ................................................................................................................................................. 38
CONCLUSION ................................................................................................................................................................. 40
AUTHOR’S REFLECTION ........................................................................................................................................... 41
REFERENCES.................................................................................................................................................................. 43
APPENDICES ................................................................................................................................................................... 48




                                                                                                                                                                                   2
Abstract

       The goal of this project is to disseminate research that recognizes and values the

contributions of CHWs, and the need to integrate their services into the standard model of

healthcare in order to decrease health disparities. Dissemination methods include a publication

and numerous conference presentations.

      The methods for this project included: 1) An exhaustive literature review, 2) a comparison

of five similar labor market studies, 3) the development and submission of an article for

publication and 4) the development and submission of abstracts to public health conferences.

       CHWs were found to be working primarily in chronic disease prevention and improving

access to health services, promoting healthy behaviors and improving the health status of

communities in a cost-effective way. Although there continues to be a lack of consensus on the

job roles and responsibilities of CHWs, what makes them successful are the personal attributes

they bring to any job such as compassion and patience.

       While there is much evidence showing the effectiveness of CHW interventions, programs

continue to struggle with unstable funding for CHW services. Not only does this affect the

services that CHW programs can provide but hampers their ability to conduct thorough

evaluations. These results were summarized into an article that was submitted for publication.

Abstracts were also completed and submitted to five conferences.

       Using this accumulation of evidence, we can work to increase the funding, power and

continued research of CHWs, and build a healthcare system that is responsive to and cost

effective for the entire population.




                                                                                                   3
Introduction

       Community health workers (CHWs) are “trusted and respected community member[s]

who provide community-based health-related services and who establish vital links between

community-based health providers and persons in the community”.2 This trust and community

respect is built upon the fact that many CHWs reflect the ethnic, linguistic and economic

diversity of the communities they serve. As a member of the communities they serve, they work

at the community level to provide health promotion, case management and service delivery

activities.3 As a link between communities and the formal health care system, CHWs are in an

ideal position to “empower community members to identify their own needs, develop a plan that

is right for them and implement the solutions”.4 The interaction between CHWs and community

members strengthens the social fabric by building community and increasing social capital.

       As culturally and linguistically under-served and under-represented communities grow

and become the majority, the health status of the entire country will be increasingly defined in

terms of the health of these communities. As the healthcare system changes to meet the growing

needs of a diverse population, an emerging and major priority will become delivering culturally

competent, high quality care at the lowest cost. Employing CHWs appears to be a cost-effective

method of delivering public health care.2 Unfortunately, the growth of the profession has been

slow. Factors such as CHWs lack of status and visibility as members of the health profession, as

well as a lack of a common job definition are two explanations.

       The Institute of Medicine, in their landmark report titled “Unequal Treatment:

Confronting Racial and Ethnic Disparities in Health Care”, found that “[c]ommunity health

workers offer promise as a community-based resource to increase racial and ethnic minorities’

access to healthcare and to serve as a liaison between healthcare providers and the communities


                                                                                                   4
they serve”5 and recommends that “[p]rograms to support the use of community health workers

(e.g. as healthcare navigators), especially among medically underserved and racial and ethnic

minority populations, should be expanded, evaluated, and replicated”.5 Other influencing public

health institutions are also recognizing the work of CHWs, with the American Public Health

Association issuing a resolution urging the recognition and support for community health

workers in 2001.6 They created a special interest group for CHWs, in order to keeps issues of

CHWs at the “forefront of the public health agenda”.7 Also, the Oregon Public Health

Association published a position paper calling for the recognition and support of CHWs, to help

make health care more accessible to communities throughout the United States.8

       A dramatic increase in research over the last ten years supports the need for the health

care system to integrate CHWs’ services into the standard model of care, in order to effectively

decrease racial and ethnic health disparities. The goal of this project is to disseminate research

that recognizes and values the contributions of CHWs, and the need to integrate their services

into the standard model of healthcare in order to decrease health disparities. The literature

shows, time and time again, how the health care safety net depends on CHWs working with

patients to promote health and manage chronic disease.

       This critical role that CHWs play in protecting the public’s health has been a focus of

local, state and federal research. At the national level, the CDC established a national database

on CHWs,3 the Annie E. Casey Foundation sponsored a comprehensive national study to

improve the overall status of CHWs,1, 3 a Robert Wood Johnson Foundation study focused on the

frontline healthcare workforce issues,9 and two new studies are in progress, one will study

feasible funding sources for CHWs10 and the other, funded by the Health Resource and Services

Administration (HRSA), will define and examine the labor market for CHWs on a national



                                                                                                     5
level.11 On the local and state level, BlueCross and Blue Shield of Minnesota conducted a study

on the use of CHWs and interpreters,12 the Massachusetts Department of Public Health

conducted a study to understand crucial workforce issues for CHWs, 13 a labor market study

researched employment trends for CHWs in the Bay Area, 14 and a more recent labor market

study of the Bay Area, examined current and future employment opportunities for CHWs.15

Conducting this research is the first step in translating science into practice, but the next step,

dissemination, requires the use of numerous approaches to reach a larger audience.

       To reach policy leaders and professionals in public health, I have chosen to disseminate

my research through publication and conference presentations. Publication is an important

dissemination strategy that can: 1) validate a researcher’s work, 2) communicate results to a

broader audience and 3) make ones research available for future access.16 By communicating

results to targeted leaders in public health, their knowledge on the subject will increase and begin

to convert research into evidence-based practice and policy changes.17 Public presentations at

conferences are also important because they provide opportunities to share research results with

a large and diverse group of public health professionals, as well as providing a possibility for

networking with those professionals.

       In order to achieve the broadest range of dissemination, this report describes the

development of an article that was produced and sent in for publication to a nationally

recognized public health journal, and the development of abstracts that were submitted to a

number of local, state and national public health conferences. In addition to publications and

public presentations, in order to frame the current research on CHWs, an extensive and

comprehensive literature review was performed, and the results of the 2005 Bay Area




                                                                                                      6
Community Health Worker Study were compared to similar labor market studies conducted over

the last ten years.



Literature Review

Topic areas that CHWs work in

        CHWs are utilized in numerous public health programs targeting racially and ethnically

diverse populations. The literature shows that a large portion of CHWs work in chronic disease

prevention interventions such as diabetes screening20-26, breast and cervical cancer screening,27-31

asthma management,32-34 general chronic disease prevention,35 HIV/AIDS prevention,36-38 and

cardiovascular risk reduction.7, 39-43 The Center for Disease Control estimate that more than 75%

of the $1.4 trillion that the United States spends each year on health care goes to medical care for

people with chronic diseases.44

        Beyond chronic disease prevention, other CHWs address general public health prevention

issues such as eye injuries,45 lead poisoning46 and STDs.47 In addition, CHWs are not only

utilized in disease specific programs. Some work on providing general information and

education around environmental health,48, 49 access to mental health services48-50 and maternal

and child health.51-54 CHWs have successfully work with communities on issues of

empowerment55, 56 and community-partnered research.57, 58

        The published research on CHWs, and their areas of work, overlaps somewhat with the

results from the 2005 Bay Area Community Health Worker Study. In that study, the areas in

which CHWs spent about half of their time (50% or less) included alcohol and drug abuse,

tobacco prevention, nutrition, HIV/AIDS/STIs/Hepatitis, violence prevention and chronic

disease.15 The areas where CHWs spent 0% of their time included re-entry services for ex-


                                                                                                    7
offenders, geriatric/aging services, home health care and environmental justice.15 This is

consistent with the lack of published research on CHWs working in these areas.



Effectiveness of CHW programs

        Communities of color currently make-up one-third of the US population and, are

predicted to increase to one half of the population by 2050.59 Results from numerous research

studies indicate that CHWs, working in communities of color, are effective in reducing racial and

ethnic health disparities.

        Although it is difficult to accurately evaluate CHW activities and their impact, there is a

sizeable amount of research that has been able to show the beneficial cause and effect of CHW

interventions.19 The specific areas in which CHWs have been shown to be effective include

improving access to health services, improving knowledge as a result of health education,

increasing behavior change and promoting culturally specific social support.19 CHWs have also

been shown to strengthen existing community networks,60 improve healthcare delivery, improve

general health status and reduce healthcare costs.


Improved access to care

        CHWs can improve access to healthcare in several areas.3, 19 CHWs not only assist in

making clinical settings more responsive to the communities’ health needs, but also change

policies to be more user friendly.42 In a study of CHW programs at seven sites in the US, CHWs

were found to impact patient’s access to care. One site accomplished this by making their

services more teen friendly based upon reviews and recommendations made by teen peer

counselors. Another site provided childcare and another site successfully conducted cultural

sensitivity training for health center staff.2 These studies demonstrate that CHWs can have a


                                                                                                      8
considerable impact on improving the communities’ access to health services, which can

potentially lead to the improvement of their health status.


Improved health status

       A number of studies have shown that improved access to health care had a positive

impact on the health status of the study participants. A study of urban African-Americans with

high blood pressure, effectively used CHWs to improve patients hypertension control through

outreach, patient education and monitoring activities.41 Another study, a randomized control trial

of low-income children with asthma showed that multiple home visits from CHWs, and

providing resources to reduce asthma triggers, significantly reduced urgent health services use.32

       Using CHWs alone is not the only way to positively affect health status. The Institute of

Medicine recommends the implementation of multidisciplinary teams to deliver treatment and

preventative services.60 Strong evidence shows that CHWs in combination with nurse

practitioners and/or physicians can lead to a reduction in coronary heart disease risk factors such

as high blood pressure and hypertension.39 In that vein, by effectively utilizing a CHW-nurse

team, the REACH-Futures program increased immunization rates for infants from 63% to 77%.53

Another study, using a nurse-CHW team approach, resulted in a lower incidence of infant deaths

then the nurse-only intervention.53 And, a randomized control trial, of a nurse case manger-CHW

team intervention on risk factors for diabetes in urban African-American populations, showed a

greater improvement in diabetic control then either intervention on its own.26 These interventions

demonstrate the effectiveness of using CHWs services alone, or in combination with other health

care providers.


Improved knowledge by providing health education



                                                                                                   9
       One main role of CHWs is providing health education on any number of topics. The

literature shows that the result of this activity is a community-wide increase in knowledge.

Brown and Hanis explain how a multidisciplinary team consisting of a bilingual nurse, a

registered dietitian and a community health worker, providing diabetes education in the

Mexican-American community, improved not only participants’ knowledge about diabetes, but

also their fasting blood sugar levels and glycosylated hemoglobin levels.25 Interventions that use

a CHW in combination with another intervention can achieve even better results. For example, a

lay health worker outreach intervention combined with a media education campaign, targeted at

Vietnamese-American women, successfully increased the women’s knowledge and obtainment

of cervical cancer screening tests.29 An unexpected result of another study, aimed at increasing

breast and cervical cancer screenings among Vietnamese-American women, was an increase in

knowledge on how to access medical care in general.27 By providing health education, the

literature shows that CHWs can effectively increase the community’s knowledge about a

particular health issue or disease.


Increased behavior change

       Behavior change is by far the clearest outcome from a CHW intervention. In a study of

Vietnamese-American women in San Francisco, health education sessions led by lay health

workers significantly increased the “recognition, receipt and maintenance of breast and cervical

cancer screening tests.”27 The study concluded that although mass media interventions can raise

awareness about screenings, the face-to-face intervention was more effective in getting women

to actually obtain a screening test.27 Another study, of uninsured Hispanic women who

participated in a randomized controlled intervention, found that women who had a home visit

with a promotora were 35% more likely to go for an annual preventive exam then those who


                                                                                                   10
only received a postcard reminder.35 Lastly, a community-based study of Hispanic cancer

survivors trained as promotoras, successfully improved Hispanic women’s obtainment of breast

and cervical cancer screening tests, with almost 40% of contacted women undergoing screening

during the study period.28 These results show that CHWs can successfully support and encourage

women in obtaining, and following up with chronic disease screenings.

       Other studies show CHWs succeeding in changing behaviors around medical follow-ups.

A randomized controlled trial of low-income urban residents with elevated blood pressure, had a

significantly increased rate (39.4%) of follow-up medical care as a result of outreach, referral

and tracking services performed by a CHW.43 Another study, of CHWs supplementing

emergency department providers in high blood pressure detection, treatment and follow-up, saw

that the CHWs improved patient appointment keeping, as well as conducting high blood pressure

screening and counseling.42

       CHWs have also been used to help communities learn preventative behaviors in order to

reduce exposure. For example, in a study of 274 low-income children with asthma CHWs were

able to increase behaviors that reduced exposure to asthma triggers such as vacuuming and other

dust control measures, use of allergy control covers and use of ventilation, through educational

home visits conducted by CHWs.33

       CHWs can also be an effective tool for reducing occupational injuries and illness. In a

controlled trial study of Latino farm workers, CHWs were used to effectively reduce eye injuries

through improving the use of protective eye equipment and improving their knowledge of eye

health and safety.45 This study, along with the other studies discussed above, continue to validate

the effectiveness of using CHWs to change behavior.


Provided culturally-specific social support


                                                                                                   11
       Since community health advisors are indigenous to their communities, they are a valuable

way of delivering culturally appropriate health education and prevention programs.1, 61 One study

found that interventions that employ CHWs, who provide social support as part of a healthcare

team, are more likely to be culturally acceptable to participants.53 Martin, in another study, found

that culturally appropriate social support in cancer prevention and control programs were also

highly effective.62 Not all programs that use CHWs to deliver social support to participants are

successful. A social support intervention aimed at Medicaid eligible women at risk for poor

pregnancy outcomes, using lay helpers, did not show a benefit in fulfilling the emotional,

informational and assistance support needs of the participants.52 Rather, the program found that,

in general, home visiting programs do not seem to be effective in improving pregnancy

outcomes.52 However overall, by providing culturally appropriate support, CHWs are more

effective in preventing and managing disease.


Strengthen existing community networks

       Another benefit of using CHWs in health interventions is the role they can play in

strengthening existing community networks.20 As members of the communities they serve,1 they

are in a unique position to connect communities members to each other. Through their social

networks, they can also address the communities beliefs, attitudes and behaviors, and develop

positive health messages.63

       One review looking at using CHWs as an important part of a research team, showed that

their inclusion creates partnerships with communities, and improves the integration of research

findings into community practice.64 A community-based participatory research project, called

Poder es Salud/Power for Health, successfully used CHWs to empower community members and

enhance social capital in order to create healthier communities.55 By creating communities


                                                                                                   12
leaders, the project left the community with the ability to continue to address health issues.55

Another lay health advisor intervention, aimed at reducing rates of STDs among young African

American women, was successful in making use of the strong social networks already

established, to initiate discussions in the community about STD prevention.47 Among

underserved Latinos, a study using Latina lay health advisors looking at cardiovascular risk

factors, was successful in delivering an educational program to reduce cardiovascular disease

risk, as well as recruiting other community members to get involved in health promotion

outreach activities.40

        The role of CHWs doesn’t end when funding for a program ends. After the conclusion of

one study, seeking to improve diabetes knowledge for Mexican-Americans, group members

continued to meet to provide support to each other in the self-management of their diabetes.25 All

these studies demonstrate how CHWs are effective in strengthening existing community

networks that build leadership, increase social capital and motivate community members to make

positive health changes.


Improved healthcare delivery

        Using CHWs allows healthcare services to leave the clinic and enter the home. In a study

of inner-city children with asthma, CHWs were able to bring some health services into the home

while at the same time, obtaining valuable medical information and providing basic asthma

education.34 CHWs also improve quality of care by helping community members navigate

through the healthcare system, by assisting in communication between patients and providers,

and facilitating patient follow-up.3 A study of breast and cervical cancer screening in low-income

women, found that using lay health advisors and a nurse practitioner to perform the screening

could improve rates of women attending outpatient clinics by 10%-15%.30 This method showed


                                                                                                   13
an even greater improvement (20%-25%) among Native American and Southeast-Asian women,

who bear a higher burden of breast and cervical cancer.30 CHWs, by meeting clients where they

are at, including in their own homes, can effectively improve the delivery of healthcare services

to diverse communities.


Reduced healthcare costs

       As healthcare costs continue to skyrocket, CHWs are often able to provide culturally

appropriate health care services that are cost-effective, and address health disparities among

underserved, hard-to-reach, racially and ethnically diverse populations.3, 4, 65 Prevention

activities, such as health education and screening, are a few of the ways that CHWs reduce

costs.3 One study reviewed six large scale international community health worker programs, and

found that the average cost of CHW services are low.66 Another study, showed that using a

nurse-community health worker team, had the potential to improve infant health in a cost

effective way.53 “The CHW case manager can make a significant contribution to both better

health outcomes and lower costs”.21

       The rise in healthcare expenditures is forcing the health system to find more cost

effective ways of providing healthcare. In a study of 117 African-American Medicaid patients

with diabetes, CHWs were shown to successfully reduce emergency room visits and

hospitalizations, resulting in an overall reduction in healthcare expenditures.21 The literature

shows that CHWs are an effective way to insure that underserved communities receive quality

healthcare in a cost effective way.



Skills and competencies of CHWs




                                                                                                   14
        The trust and community-wide respect that CHWs possess is built upon the fact that they

reflect the racial and ethnic diversity of the communities they serve. Shared experiences, and

experiential knowledge, are important resources that CHWs bring to their job. For example,

many shared life experiences including recovering from addiction or experiencing homelessness,

allow CHWs to act as role models for peers in the community.2 As cultural insiders to the

communities that they serve, many of the most valuable
                                                                  Qualities
                                                                  ♦   Compassion
qualities that CHWs possess, are their own personal               ♦   Patience
                                                                  ♦   Caring
attributes. These include compassion, patience, 1, 12, 61, 67     ♦   Empathy
                                                                  ♦   Warmth
                                                                  ♦   Sensitivity
“...caring, empathy, warmth, sensitivity, genuineness,            ♦   Genuineness
                                                                  ♦   Openness
openness, calmness, confidence, and respect for the client.       ♦   Calmness
                                                                  ♦   Confidence
A non-judgmental attitude, maturity and emotional                 ♦   Respect for the client
                                                                  ♦   A non-judgmental attitude
                                                                  ♦   Maturity and emotional stability
stability, and good listening skills are [also] essential”.50         Good listening skills
                                                                  Reference: 1
These individual traits are what make for a successful

CHW2 and successful agents of change.3 A study of employers of CHWs and interpreters,

conducted by Blue Cross and Blue Shield in Minnesota, confirmed these results.12

        Of secondary importance to a CHWs personal qualities, are the professional skills that are

                                 gained through study and practice.67 Based upon the results of the
  Skills
  ♦    Communication
  ♦    Knowledge base
                                 National Community Health Advisor Study, these skills include
  ♦    Capacity building
  ♦    Interpersonal skills      communication, interpersonal skills, knowledge base, service
  ♦    Service coordination
  ♦    Teaching                  coordination capacity building skills, advocacy, teaching and
  ♦    Advocacy
  ♦    Organization
  Reference: 1                   organizational skills.1 Another important professional skill is

                                 bilingual/bicultural fluency.3, 50 For some organizations, this is

one of the few skills that uniquely qualifies someone to be an effective CHW.3



                                                                                                         15
Roles, responsibilities and activities of CHWs

       CHWs serve a number of different roles and perform a wide variety of functions within

those roles. Although the literature specifics some primary CHW responsibilities, there is a

general lack of consensus regarding the definition and roles of a CHW.19 In general, one CHW

described their role as “the ‘glue’ between the clinic and the community”.67 The National

Community Health Advisor Study1 distilled the various responsibilities of a CHW into the

following seven core roles:

   ♦   Cultural mediation between communities and the health and human service system
   ♦   Informal counseling and social support
   ♦   Providing culturally appropriate health education
   ♦   Advocating for individual and community needs
   ♦   Assuring people get the services they need
   ♦   Building individual and community capacity
   ♦   Providing direct services


       Additional literature agrees with a number of these roles.2, 4, 7, 36, 39, 50, 60, 64, 67-74 Other

CHW activities that are defined in the literature include:

   ♦   Outreach
   ♦   Case management
   ♦   Health promotion and lifestyle changes
   ♦   Assisting in appointment attendance and adherence to medication regimens
   ♦   Helping to increase the use of preventative and primary care services
   ♦   Collecting health related data
   ♦   Promotion of self-care skills
   ♦   Referral and follow-up assistance 2, 4, 7, 36, 39, 50, 60, 64, 69, 70, 73, 74

       One study of CHWs found that the activities CHWs state that they perform include

information and referrals (94%), health education (91%), translation (73%), advocacy (66%) and

case finding services (55%).67




                                                                                                            16
       CHWs perform these responsibilities in many different roles, including educators,

outreachers, case managers and data collectors.19 In research, CHWs assume roles such as

research assistants, recruitment coordinators, data collectors, interventionists and project

coordinators.64 Some roles involve multiple levels of responsibility such as social support. For

example, many levels of social support that CHWs provide include emotional and appraisal

support at the one-on-one level, informational support at the group level, and instrumental

support at the community level.36, 63

       When looking at the roles, responsibilities and activities of CHWs in regards to specific

interventions, Earp and Flax68 found, that CHWs help increase mammography screening by older

African American women in North Carolina. In that study, lay health advisors were reported as

“willing to draw on a variety of strategies to reach women in their social networks [through] the

numerous locations of group presentations such as churches, work, senior centers and private

homes”.68 Also, the activities of lay health advisors complement and don’t compete with the

formal health care system.68 McQuiston et al., in a study aimed at preventing HIV/AIDS among

recently immigrated Mexicans in North Carolina, found that CHWs provide information and

referrals about prevention of HIV and other STDs, direct assistance such as making

appointments, handing out condoms and providing transportation and culture specific emotional

support.36 In conclusion, CHWs provide many different services to their communities and play

many different roles, but are always the link from the community to the wider healthcare system.



Funding Instability for CHW Services

       Sustainability for CHW services is a major concern, due to the lack of stable funding

dedicated to CHW services.2, 3, 7, 74 Ten years ago, budget constraints were the overwhelming



                                                                                                   17
reason that CHWs were not used on a wider basis.14 Recently, four other studies have confirmed

that CHWs are still not employed on a wider basis due to unstable funding.9, 12, 13, 15 Without

stable funding, CHWs’ job stability is threatened and attrition rates continue to skyrocket. The

Robert Wood Johnson Foundation found that, due to the “patchwork nature of funding” for these

positions, job security and high attrition rates are a critical concern nationwide.9 In Minnesota

and Massachusetts, employers and CHWs are finding that government grants are not adequate to

fund CHW activities, and provide very little job security.12, 13 Even public health institutions are

recognizing the effect of inconsistent funding on the use of CHWs.6, 8, 60 Funding instability

stifles the growth of the field of community health work, and is a considerable barrier to

integrating CHW services into health service delivery.7, 74



Gaps in the literature

        In summary, CHWs are working primarily in chronic disease prevention and are making

huge impacts on improving access to health services, promoting healthy behaviors and

improving the general health status of communities in a cost effective way. Although there

continues to be a lack of consensus regarding CHWs job roles and responsibilities, what makes

CHWs successful are the personal attributes they bring to any job, such as compassion and

patience. While there is a mountain of evidence documenting the effectiveness of CHW

interventions, programs continue to struggle with a lack of stable funding for CHW services.

Not only does this funding instability affect the services that CHW programs can provide, it also

hampers their ability to conduct thorough evaluations of the contributions that they are able to

make.




                                                                                                    18
       Evaluating CHW programs is necessary in order to establish their relevance and

effectiveness in meeting community health service needs.75 Although studies of CHW

effectiveness assert that further evaluation of CHW services is recommended, both at the process

and outcome level, 19, 20, 60 published evaluations are uncommon.1, 4, 63 One article, summarizing

evaluations of CHW programs, found only ten articles that described either process or outcome

evaluations.4

       One reason why more evaluations of CHWs are not conducted, is the limited funding to

cover the cost of comprehensive evaluations.1, 6, 74 Another reason is that CHW activities are

sometimes spontaneous, and take place in very informal settings (churches, hair salons, grocery

stores, peoples’ homes, etc), and therefore, can be difficult to document and measure their

contributions to improving health.1, 6, 62 In order to continue supporting CHW activities,

resources for evaluations need to be incorporated into funding allotments and functional and

responsive methods of evaluation must be developed.1



Publishing in Academic Journals

       Publication serves three main purposes: 1) validation of a researcher’s work, 2)

communication of results to a broader audience and 3) enabling ones research to be accessible in

the future.16 In this project, publication is important in disseminating research on CHWs in order

to translate research into action and future interventions.

       Publishing is a useful part of this project, and to the CHW community, because it puts my

results into the hands of professionals in the field, who can incorporate those results into their

practice, in order to improve community interventions.17 Through publishing, I am also

communicating my results to a broader audience, thereby increasing the knowledge of policy



                                                                                                     19
leaders and public health professionals, about the impact of CHWs on the health of communities

of color. This communication effectively converts research into evidence-based practice and

policy change.17

       The other important role of publishing, is adding to the growing body of literature on

CHWs. As the literature on the use of CHWs grows, their status and integration in the health

system increases. Publication allows me to contribute to the current public health discourse

regarding CHWs, as well as preserves my research for future accessibility.

       In reviewing the literature on writing for publication, many articles established the

reasons why practitioners do not publish and listed the multiple steps to the publication process.


Why practitioners do not publish

       Many health professionals help communities deal with important health and social issues

on a daily basis, yet very few disseminate their knowledge to the general public. One reason for

this includes the additional time and energy required, in addition to already long workdays, to

write an article for publication.17 Also, for many health professionals, the importance of

publishing is not stressed, and the skills needed to publish are not promoted in their professional

development.17 Lastly and sometimes most importantly, fear of rejection can halt the publication

process before it even gets started.76 Some ways to overcome this fear re to learn the rejection

rate of the journal you intend to submit to, and learn to accept rejection as “natural and

necessary” to the process of becoming an accomplished writer.76


Publication Process

      Whereas the publication process can be daunting when undertaken for the first time,

organizing the process can make it more straightforward and attainable. The first step in the



                                                                                                   20
publication process is setting a timeline.77, 78 This will help to organize the remaining steps

needed to achieve publication, as well as help the potential author manage their time. The first

major task in the timeline should be selecting the appropriate journal to submit to.

      Doing research ahead of time to, find the most appropriate journal to submit a manuscript

to, can be time well spent. Studying what topics and issues current health journals are

publishing, helps one formulate topics that are the most viable for publication.17 Another

important aspect of journal selection is “[m]atching the manuscript to an appropriate journal

readership and focus...”.17 Although a journal’s audience is important, other sources of

information to pay attention to include: 1) the journal’s mission statement, 2) the table of

contents and 3) the format, style, voice and intended audience.79 The last part of journal selection

should be contacting the editor of each potential journal and inquiring if the journal would be

interested in an article on your topic.79

      Every journal has their own guidelines on how to format article submissions. These

guidelines will lay out in detail the format and style the article should adhere to as well as

specific procedures for submission. Not following these guidelines could potentially be a major

strike against you before your manuscript is even read.79 In surveys of editors, the single biggest

mistake they say is the reason for most rejections is not following the author’s guidelines.76

      Once you have researched the best journal to submit to, and have read and understood the

author’s guidelines, you can begin to write an outline of your article. The next step of writing is

to begin a rough draft of the article, which should start with trying to get the major concepts and

information down on paper without worrying about format or organization.77, 79 Once you have

the first rough draft, plan to revise this draft at least three times with the help of co-authors or

colleagues.79 The last step for finalizing the manuscript is to refine the article through a final edit



                                                                                                       21
and review.77

      The last step of the publication process is submission. The author’s guidelines will specify

the submission process, including whether they will accept a hard copy or electronic submission,

and the number of copies needed. To complete the submission package, a concise cover letter to

the editor, with a description of what is enclosed, should be included.77, 79

      Once an article is submitted, an editor will review and pass the article on to a panel of peer

reviewers who will critique the article.17 The editor then can make one of four decisions: 1)

accept for publication with no revisions, 2) accept for publication with minor revisions, 3) state

that substantial revisions are necessary for the article to become a publishable piece, or 4)

reject.17 With all feedback from editors, it is important to review and incorporate the feedback or

provide a reasonable argument for why a suggested change was not made.17, 76, 77



Goals & Objectives

                                                Goal
To recognize and value the services that CHWs provide as well as the need for the health care
system to integrate their services into the standard model of care in order to effectively decrease
racial and ethnic health disparities.

                                      Impact Objective 1
To increase the knowledge of policy leaders and public health professionals about the critical
role of CHWs and their impact on the health of communities of color.

                                     Process Objective 1.1
Develop a complete article for publication by a nationally recognized public health journal.

                                       Process Objective 1.2
Publish article in a nationally recognized public health journal.

                                  Process Objective 1.3
Conduct a comprehensive and exhaustive literature review on the use of CHWs in the past 20
years.

                                       Process Objective 1.4


                                                                                                     22
Compare and contrast results of five labor market studies of community health workers
employed in diverse urban areas.

                                     Process Objective 1.5
Research appropriate public health conferences to submit abstract to.

                                      Process Objective 1.6
Submit abstracts to four public health conferences.



Methods

     The methods described below are for the following four parts of the project: 1) exhaustive

literature review, 2) comparison of labor market studies, 3) publication process and 4)

conference submissions.



Exhaustive Literature Review

       A review of the literature to identify the use and employment of CHWs over the past 20

years was conducted. Numerous search methods were employed in order to conduct a

comprehensive search. First, key words such as community health worker, health educator, lay

health advisor, lay health worker, health outreach worker and promotore/a were used to search

public health and social science databases and the Internet. Second, existing literature reviews

on CHWs were searched including the South Texas Health Research Center - Community Health

Worker Program Resources, the Texas Department of State Health Services - Community Health

Worker Research Materials Archive and the University of Washington Community Campus

Partnerships for Health. Third, the technique of searching the reference sections of other papers,

also called, citation searching and footnote chasing18 was used. Fourth, I consulted with others

who are knowledgeable on the subject and obtained their information on possible sources. These

four strategies were used to search a variety of media sources including books, journal articles,

                                                                                                    23
Internet sites, theses, existing literature reviews on CHWs, conference papers, and government or

industry reports. Special attention was paid to landmark or influential works in the field of

community health work. The researcher was confident in the exhaustive nature of the literature

review when repetition of a number of articles was found. These methods produced one hundred

(100) publications.

       Each source was then reviewed and key points such as the research question, specific

hypotheses, findings, and main conclusion(s) were summarized. Each source was then reviewed

again and grouped into theme areas. The following five themes emerged from the review of the

literature: 1) topic areas that CHWs work in, 2) effectiveness of CHW programs, 3) skills and

competencies of CHWs, 4) the roles and responsibilities of CHWs and 5) funding instability for

CHW services. Gaps in the literature center on the lack of empirical outcome and process

evaluations of CHW programs.19 Many articles were grouped into more then one theme area.

The reference management program, EndNote 9, was used to manage the references, create in-

text citations and create the bibliography.



Comparison of labor market studies

       A second review of the literature was conducted to locate labor market studies of CHWs

similar to the Bay Area Community Health Worker Study. Keywords including labor market,

employment, community health worker, lay health advisor, outreach worker and promotore/a

were used to search public health and social science databases and the Internet. Also, the

reference sections of other papers were reviewed. Inclusion criteria included a focus on US-

based CHWs and studies of employment issues of CHWs. Four studies were found that fit the

inclusion criteria. Three of them were similar to the Bay Area Community Health Worker Study



                                                                                                24
in that they surveyed CHWs and/or employers of CHWs,12-14 while the last study focused on

collecting information from secondary data sources.9

       A codebook was used to document relevant variables. The variables included similarities

and differences grouped into the five following areas: 1) current and future hiring needs, 2)

functions and skills of CHWs, 3) profile of a CHW, 4) advancement opportunities and 5) barriers

to wider employment.



Publication Process

       A review of the literature was conducted to locate sources on how to publish in an

academic journal. Key words such as publication, academic journals, publishing research and

writing for publication were used to search public health and social science databases. The

literature on writing for publication stressed overcoming the fear of rejection and the steps of the

publication process, beginning with selecting the right journal for your target audience and

finishing with what to do if your manuscript is rejected.

      A review of all journals available to public health professionals, including a mixture of

general journals and specialty journals that focus on community health work, was conducted.

Special attention was paid to journals that frequently publish articles related to CHWs. A

spreadsheet (Appendix A) of nine journals was created that tracked different aspects of each in

order to determine the top three journals that would be appropriate for article submission. These

aspects included description of the journal, the journal’s mission, the target audience and its size,

types of articles accepted and impact factor. Two to three recent issues of each journal were

examined. The spreadsheet of the journals was then reviewed and three journals; The American

Journal of Public Health, Health Education and Behavior and Health Promotion Practice, were



                                                                                                   25
selected and ranked in order of appropriateness for submission. The author’s guidelines were

obtained for the first choice journal, The American Journal of Public Health and reviewed.

      Concurrently to the process of determining which journal to submit to, a timeline for

submission was developed that included tasks such as creating an outline of the paper with main

headings and a title, developing several drafts and revisions that respond to reviewers comments,

preparation of final tables, graphs, figures and abstract, creation of a final draft, final edit for

format and grammatical errors and then sending out the final copy. The first rough draft was

prepared and emailed to the following reviewers:

      1) Mary Beth Love, Department Chair of the Health Education Department at San

      Francisco State University and the principal author on the last CHW labor market study in

      1996.

      2) Richard Harvey, Assistant Professor in the Department of the Health Education

      Department at San Francisco State University who has knowledge and experience in the

      health policy field and has recently worked on publishing a policy brief related to

      preventing youth tobacco use.

      3) Len Finocchio, Professor in the Department of the Health Education Department at San

      Francisco State University who has worked in the health policy field for over 14 years. His

      research has also been published in Academic Medicine, American Journal of Public

      Health, Health Education and Behavior, and Public Health Reports.

      4) Vicki Legion, Director of Community Health Works and faculty at City College of San

      Francisco in the Community Health Worker Certificate program who was also involved in

      the publication of the last labor market study of CHWs.

      5) Cindy Tsai, Training Director of Community Health Works who has fifteen years of



                                                                                                       26
      experience working with CHWs. She sits on the advisory committee for Center for

      Sustainable Health Outreach, and co-founded a national network of college supported

      CHW Programs.

      After reviewing several current issues of the American Journal of Public Health, guidelines

were put together for reviewers. Reviewers were asked to pay attention to general content

clarity, clarity of main argument, areas for improvement, sections to expand or condense,

sections to highlight and figures and graphs that clarify the content.



Conference Submissions

      All public health conferences were researched and a schedule of upcoming conferences

was compiled (Appendix B). Five conferences were found to be appropriate for abstract

submission including: 1) American Public Health Association, 2) Society for Public Health

Educators, 3) California Public Health Association – North, 4) California Community College

Association for Occupational Education and 5) The National Council of Workforce Education.

Guidelines for abstract submission was reviewed for each conference and abstracts were

prepared (Appendix C, D, E & F). Abstracts will be submitted between December 2005 and

May 2006 depending on the specific deadlines for each conference.



Results

       The results of this dissemination project include a comprehensive comparison of five

labor market studies focused on CHWs, submission of a reviewed manuscript to the American

Journal of Public Health and submission of abstracts to five public health conferences.




                                                                                               27
Comparison of CHW labor market studies

       Over the last ten years, five studies were conducted that sought to understand the

frontline healthcare workforce specifically focused on community health workers. Four of them

were similar in that they surveyed CHWs and/or employers of CHW12-15 while the last study

focused on collecting information from secondary data sources.9

       In the summer of 2005, the Bay Area Community Health Worker study was conducted

with the purpose of studying current and future employment opportunities for Community Health

Workers (CHWs) in four counties of the Bay Area. A stratified random sample of employers of

CHWs in four counties of the Bay Area yielded a sample of 248 organizations. An online

survey, modeled after the tool used by Love et al., consisting of 38 questions, was emailed to 134

employers with a response rate of 50.75% (68).15

       Almost ten years earlier, Love et al. (1997) conducted a study to “gather descriptive data

on the roles, backgrounds and working conditions of CHWs [in the Bay Area]”.14 A systematic

telephone survey of healthcare providers in eight counties of the Bay Area produced 269

organizations that participated in the study, with a response rate of 76% (197).14

       In May 2003, Blue Cross and Blue Shield of Minnesota conducted a study looking at the

role and uses of CHWs and interpreters in Minnesota.12 Their telephone survey, modeled after

the tool used by Love et al., included 156 key informants who employed CHWs in 44 counties of

Minnesota. This study had a high participation rate at 90%.12

       Another similar study conducted in March 2005, sought to better “understand critical

workforce issues such as job role and scope, training and supervision, level of integration into

the health care delivery system, and barriers to recruitment and retention,”13 in order to improve

health outcomes in Massachusetts. Eight thousand agencies and individuals were interviewed to



                                                                                                   28
determine their eligibility.13 Surveys were mailed to 806 CHWs and 155 supervisors who met the

eligibility criteria, with a response rate of 46% (371) for CHWs and 67.7% (105) for

supervisors.13

       Lastly, in September 2005, the Robert Wood Johnson Foundation (RWJF) executed a

study of secondary data sources with the purpose of understanding the frontline healthcare

workforce and identifying areas for investment. The method used a collection of US-based

secondary data sources primarily acquired via the Internet that were five to seven years old.

Data sources included journal and news articles, published data and reports from various federal,

state and local agencies, academic and think tank studies, and a variety of career development

and educational program resources.9

       Each study was compared to the Bay Area Labor Market Study and the similarities and

differences were grouped under the five following themes: 1) current and future hiring needs, 2)

functions and skills of CHWs, 3) profile of a CHW, 4) advancement opportunities and 5) barriers

to wider employment.


Current and future hiring needs

Community Health Work: High growth occupation

       Four of the five studies showed that all over the county, the field of community health

work is growing. In one study of the San Francisco Bay Area, the results showed that thirty-

three of sixty-one organizations responding to the survey, projected 121 new CHW positions (an

average of 3.6) in the next three years.15 In reviewing the literature nationwide, the RWJF found

that “a 49% increase in openings due to growth [are] projected...for 2012”.9 Also, with 50,000

jobs opening up due to retirement and advancement, there will be a total of 200,000 new job

openings for social and human service assistants.9 In Minnesota, the need for CHWs is also


                                                                                                 29
growing, with more then one-third of respondents stated that they were very likely to increase

their numbers of CHWs in the future.12 This growth is also not new. In 1997, Love et al., survey

respondents estimated hiring 263 CHWs over the next three years, showing that, like currently,

the CHW field was growing.14

       In the Bay Area, the growth seems to be primarily with county health department as the

biggest employer followed by community-based organizations/community clinics.14, 15 In

Minnesota, growth is focused in metro organizations and community-based organizations.12 The

Robert Wood Johnson Foundation study found that due to funding availability on a national

level, faster growth is predicted in private agencies verses public agencies.9


Incorrect identification of CHWs due to lack of a standard title

       Although CHW programs have been around since the 1960’s, there is still no unified title

that describes this worker. Some of the more commonly used titles include, community health

specialist, lay health advisor, health educator, health facilitator, community health outreach

worker, peer advocate and promotore/a. Lack of a standard title sometimes leads to incorrect

identification of CHWs employed. Due to this incorrect identification, in two of the five studies,

it is possible that there was an underestimation of CHWs employed. In one study of sixty-eight

respondents, although participants were screened to ensure they employed CHWs, only 62%

reported employing CHWs, while 31% reported having no CHWs.15 In another study of 197

prescreened respondents, 26% of organizations reported employing CHWs or planning to in next

three years, while 47% reported employing no CHWs.14 In another study, that did not prescreen

respondents, 59% of respondents stated that they employ community health workers while 41%

do not.12 This lack of consistency is not only associated with a CHWs title but also with a

standard definition of a CHW.


                                                                                                 30
         One study found that not only were there almost 50 job titles that fell under the CHW

“umbrella”, but there also was a “lack of a consistent, widely accepted CHW definition”.13 To

begin to address this issue, the study sought to establish a standardized definition for a CHW,

which could then be used for practice and service contracts.13


Functions and skills of CHWs

Skills

         Core skills of a CHW that were shown in three of the five studies were communication

and conflict resolution.13-15 In one study, communication and conflict resolution was not only

very important for hiring but it was also very to moderately difficult to find applicants with these

skills.15 Another skill that was found to be in common to three of the five studies was knowledge

of the community that CHWs serve.12, 13, 15 In one study it was rated as extremely important by

51% of respondents.12 Lastly, two of the studies found that the most important skills that

employers are looking for are sometimes the skills that are within the self such as patience,

maturity and persistence.12, 15 The two skills that respondents stated were very important in the

Bay Area Community Health Worker study that were not stated in any of the other studies were

the ability to document work and write clear reports and bilingual/bicultural competency.15

         Two studies noted that having a vocational certificate, such as a CHW certificate, was

seen as a valuable asset to hiring employers and could be an entry into the field.9, 15 Although

having a vocational certificate was important to some employers, it was also difficult to find

qualified applicants who had one. Contrasting that, in one study respondents stated that

specialized training in CHW role was not as important as other skills.12


Areas of practice



                                                                                                    31
       CHWs work in numerous topical areas, which may be determined by the agencies focus

and program funding. In different parts of the US over the past ten years, the area of HIV/AIDS

continues to employ high numbers of CHWs. Three of the studies showed a high concentration

of CHWs working in HIV/AIDS and alcohol and drug abuse.12, 14, 15 With an aging population, it

was not surprising to find that two of the more current studies, conducted in the past few years,

also showed high concentrations of CHWs working in chronic disease management.12, 15 In 1997,

high concentrations of CHWs were also working in maternal/child health (16%) and primary

care (10%).14 In 2005, the other areas where CHWs are spending about half of their time

included tobacco prevention, nutrition and violence prevention with no paid CHWs employed in

re-entry services for ex-offenders, geriatric/aging services and environmental justice.15


Profile of a CHW

       Overall, CHWs tend to be female (65%-76%).9, 13-15 When looking at ethnicity, the

picture changes depending on where you are in the county. Although nationwide, CHWs are

60% white, in the Bay Area, over 70% of CHWs are from communities of color14, 15 and in

Massachusetts 80% of CHWs are white.13 The four studies that report educational levels among

CHWs show a difference between nationwide, Bay Area and Massachusetts. In the Bay Area,

over 50% of CHWs have only a high school degree, although in 2005 almost 30% had an

associate degree which is up from 1997 when only 19% had an associate degree.14, 15 In

Massachusetts, 60% hold some form of a degree beyond high school and 12.5% hold only a high

school degree.13 Nationwide, 60% have at least a bachelor’s degree.9 Although educational

background is varied among CHWs nationwide, the CHW position is an entry point for many

into the healthcare and human services regardless of their academic preparation.




                                                                                                    32
       As an entry level position, the average pay rate for CHWs is under $30,000 with a

majority of full-time CHWs in the Bay Area receiving health benefits.14, 15 Comparatively,

nationwide, many CHWs are employed part-time with no access to fringe benefits such as health

insurance.9


Advancement opportunities

       In the last few years, fewer agencies are providing a structured career ladder for the CHW

position. Only 25% of employers surveyed stated that they provide a structured career ladder or

series for entry-level CHWs to advance in their careers, although almost 60% feel that there are

some advancement opportunities for CHWs at their organization.15 Similarly, Ballester found

that 76% of CHWs reported that there is no formal career ladder to advancement and building

skills and increased levels of responsibility within their current position was the only opportunity

for advancement available to them.13 The advancement that is possible mostly includes

promotion to supervisory positions.9, 13 Ten years ago, 60% of survey respondents reported that

the CHW position has a career ladder or series within the CHW classification.14 Advancement

for CHWs centers on the development of career paths which would not only retain qualified and

experienced employees but has the potential of attracting more people to the role. Education can

also play a large part in the hiring and advancement of CHWs. Collaboration between

community organizations and local academic institutions can help to develop customized on-

going staff development courses to meet employers’ needs.


Barriers to wider employment

       Four of the five studies found that the overall reason that CHWs are not employed on a

wider basis is unstable funding. Budget constraints was overwhelmingly the response (74%)

from surveyed employers, with limited opportunities for promotion (27%) a far second.15 This is

                                                                                                  33
not a new trend. Ten years ago budget constraints was still the overwhelming response with

91% of respondents choosing this option.14 Nationally, the Robert Wood Johnson Foundation

found that due to the “patchwork nature of funding” for these positions, job security and attrition

rates as high as 77% are a critical concern.9 Over 80% of surveyed organizations in Minnesota

use government grants to fund CHW positions, which are not adequate and unstable.12 Another

barrier in Minnesota are the numerous small pockets of ethnic and non-English speaking

populations that need CHW assistance.12 Unfortunately, it is not financially feasible for most

organizations to employ specialized CHWs for such small populations. Lastly, the shortage of

qualified workers with the necessary skills to be effective CHWs stifles the growth of CHWs in

Minnesota.12 In Massachusetts, job retention is low and turnover is high due to unpredictable

funding and lack of a formal career ladder for advancement.13 Unstable funding impacts CHWs

with 77% of surveyed CHWs unsure of the security of their job due to unstable funding.13



Publication

       The American Journal of Public Health (AJPH) was chosen as the primary journal to

submit to, based on a number of factors. First, the type of work that the journal publishes and

their mission to advance public health research, policy, practice and education is aligned with the

research topic. Secondly, I am seeking to reach and influence professionals and policy leaders in

the field of public health and the AJPH has a wide audience with readers representing over 70

public health professions. Lastly, as a journal of the American Public Health Association, the

AJPH is a nationally recognized journal that is well respected in the field and frequently cited

with an impact factor of 3.261. If the article is not accepted for publication by the AJPH, the

second choice journal is Health Education and Behavior and the third choice is Health Promotion



                                                                                                   34
and Practice. Both of these journals are affiliated with the Society of Public Health Educators

and publish numerous articles relating to community health workers.

       Two drafts of the article were produced and reviewed by five reviewers. Suggestions on

the first draft included weaving in the social justice aspect of CHWs and their work, creating a

more powerful message about the necessity of CHWs in the healthcare delivery work force,

more clearly stating the research objectives, using a previous article on the MPH labor market as

a template and condensing the length of the article.

       Revisions were made to the first draft and it was emailed to all five reviewers again for a

second round of feedback and critique. Two of the five reviewers were unable to review due to

other commitments. The three other reviewers made no other suggestions.




Conferences

       A review of both local, state and national public health conferences as well as other

avenues for public presentation was conducted in order to establish the most appropriate forums

for public presentations of research results. Five conferences were selected to disseminate

research results based on their specific target audience as well as size. Therefore, abstracts were

prepared for and submitted to the following five conferences: 1) American Public Health

Association (APHA), 2) Society for Public Health Educators (SOPHE), 3) California Public

Health Association – North (CPHA-N), 4) California Community College Association for

Occupational Education (CCCAOE) and 5) National Council for Workforce Education (NCWE).

Two abstracts, for CCCAOE and NCWE, were prepared in collaboration with faculty from the

Health Education and Community Health Studies Department at City College of San Francisco.

Abstracts were submitted between December 2005 and May 2006.


                                                                                                   35
       Results were also presented in two other forums. In January 2006, results of the Bay

Area Community Health Worker Study were presented to faculty and staff of the Health

Education and Community Health Studies Department at City College of San Francisco. In May

2006, results were displayed in poster format at the San Francisco State University Graduate

Research and Creative Works Showcase.



Discussion

       After over 20 years of using CHWs in healthcare, the same issues are still present.

CHWs continue to go by over 50 different job titles, with no one unifying title. There are also

still no agreed upon and clearly defined job responsibilities for CHWs. Both of these challenges

lead to incorrect identification of CHWs. By grossly underestimating the CHW workforce,

policy recommendations lack the power and force to move forward. Other challenges include

unstable funding and a lack of job security, which continue to threaten CHW programs across the

nation. Lastly, there are very few opportunities for advancement with only a handful of

employers offering a structured career ladder for advancement.

       There are three overlapping goals that influence health outcomes: strengthening

therapeutic alliance, improving appropriate healthcare utilization, and reducing health risks.4

Encouraging a strong patient-provider relationship can increase access to healthcare and improve

adherence to health behaviors. By appropriately utilizing healthcare services, the risk of disease

is reduced and the need for tertiary care and services is dramatically reduced. CHWs are the key

for cultivating this cycle to ultimately result in reduced healthcare costs, improved service

delivery and an increased health status. If CHWs can be used to create an ideal world, where




                                                                                                  36
communities are healthy and the health system is responsive to their needs in a cost effective

way, then how can we continue to ignore the value of their services?

       Currently, more and more evidence continues to show the effectiveness of using CHWs

to, not only, improve knowledge, increase behavior change and strengthen existing community

networks but the use of CHWs can significantly reduce healthcare costs. These improvements

result in improved delivery of and access to healthcare services, which, in turn, result in an

enhanced health status of the population as a whole. Continuing to ignore the vital role that

CHWs play in connecting communities to the healthcare system not only affects the CHW, but

also is traumatic for the communities that depend on their services.

       CHWs are by their nature from the communities that they serve. These communities tend

to be racially and ethnically diverse underserved populations and are most likely to be

disproportionately affected by disease, especially chronic disease. To compound the problem,

many are uninsured or on Medicaid and are more likely to depend on the healthcare safety net.

A community with a well-developed safety net is more prepared to serve its community

members. By helping to promote healthy behaviors and gain access to appropriate preventative

services, CHWs are a key component of a well-developed health safety net. With over 75% of

the healthcare budget in the US being spent on chronic disease,44 encouraging self-management

and prevention activities can help bring that cost down. Cost containment as well as quality

improvements, are both important aspects of our new healthcare system that has moved to a

more managed care model.

       Without CHWs, communities become culturally and linguistically isolated from the

healthcare system. This isolation prevents community members from gaining skills to prevent

and manage chronic disease, leaving large numbers of community members depending heavily



                                                                                                 37
on emergency services. Costs for chronic disease management moves from cost effective

prevention to costly tertiary services and care. Also, as communities of color grow and become

the majority, their health status becomes the overall health status of the nation. If their health is

declining, then “the health of the nation deteriorates, the social fabric unravels, and the cost of

maintaining community goes up.”80

       With a complex health care crisis facing the nation, CHWs can be a key element in

avoiding the crash our healthcare system is facing. In order for CHWs to be effective in heading

off this “train wreck”, we need to focus on making system wide changes that allow us to move

forward and address the issues that continue to plague the field of community health work.



Recommendations

       In order to obtain recognition for CHWs and facilitate their integration into the healthcare

system, sixteen recommendations were developed. They can be grouped under three main

themes: stable funding, increased power and continued research.


Stable Funding

       Unstable funding through short-term grants and multiple soft money funding sources has

stunted the growth of the field of community health work for over 20 years. In order to continue

the advancement and sustainability of CHWs, we need to:

       1) Develop permanent funding streams from hard money sources, like insurance

           reimbursements.

       2) Increase fiscal flexibility that funds the varied activities that CHWs perform.

       3) Dedicate money for the evaluation of CHW programs.

       4) Create Medicaid reimbursement codes to pay for CHW services.

                                                                                                      38
       5) Develop a Department of Labor classification for this worker.6, 7

       By investing in the crucial infrastructure of CHW programs, we can create financial

security for CHW programs and give CHWs stronger job security.


Increased Power

       The lack of power that CHWs have comes from a myriad of reasons including unknown

numbers of paid and unpaid CHWs, a general lack of respect and understanding of their services

by other health professionals and very few advancement opportunities. It is important that we

work towards obtaining recognition for the valuable services CHWs provide by:

       1) Creating more opportunities for CHWs involvement in program planning and

           decision-making.

       2) Increasing their membership in public health organizations such as APHA, SOPHE.

       3) Continuing to develop national, state and local associations of CHWs that provide

           leadership and advocacy to build professional recognition and advance the field.

       4) Building a diverse base of support for CHW services among health and human

           service professionals to create a unified voice that promotes the necessity of CHWs.

       5) Follow the recommendation of the Institute of Medicine to increase support for

           integrating CHWs into multidisciplinary health care provider teams.

       6) Building structured internal and external career ladders for CHWs.


Continued research

       As previously stated, more and more evidence continues to mount on the effectiveness of

CHWs. In order to continue to build the case for investments of resources in CHW programs,

evaluations of successful CHW interventions need to be researched and disseminated through



                                                                                                  39
publication, replication and public presentations. Therefore, I make the following

recommendations:

       1) Continue to conduct and publish randomly controlled trial evaluations as well as

           evaluations of larger scale CHW interventions.

       2) Publish evaluation results of successful CHW interventions in order to inform the

           development of other CHW programs. Sharing the evidence of successful programs

           allows better translation of research into practice and policy.7

       3) Increase the involvement of CHWs in designing, implementing, analyzing and

           disseminating evaluation and research studies of CHW programs and interventions.

       4) Conduct more studies on the cost effectiveness of CHW interventions.

       5) Develop a best practices manual to inform the development of other CHW programs.1



Conclusion

       Although the growth of community health workers has been slowed by the same

problems it has been dealing with for the past 20 years, evidence continues to mount on the

effectiveness of CHW interventions. Current research specifically focused on the labor market

for CHWs, continues to produce similar findings across the United States. Using this

accumulation of evidence, we can work to increase the funding, power and continued research of

these workers and build a healthcare system that is responsive to and cost effective for the entire

population. A more responsive healthcare system that uses CHWs to deliver high quality

healthcare and increase access to health services, unites communities and strengthens the social

fabric. A healthcare system that is accessible to all promotes respects of the individual while at

the same time meets the communities’ needs.81


                                                                                                  40
Author’s Reflection

        The process of conducting the Culminating Experience (CE) was both challenging and

rewarding. The challenges came not only from the academic demands but the personal demands

of having a new baby as well. Academically, this project challenged my writing skills through

the writing of the report as well as the development of a well-polished article ready to submit for

publication. Also, taking the large amount of information that I had collected, both through the

literature review as well as my research results, and synthesizing that down to 3,500 words for

the article was difficult.

        Personally, with a new baby, finding the time to dedicate to writing and researching was

not easy. I was lucky to have plenty of help from friends and family. My in-laws even came out

from Hawaii twice to spend time with my daughter and give me much needed time to work on

my CE. Juggling my time between my new daughter and my research made it important that I

make the most out of the chunks of time that were set aside to work on my CE. This has been an

amazing learning experience for me. It has also been extremely satisfying to seeing how much

work I was able to get done over the last two semesters and produce a final product that I am

proud of.

        Other rewards are the relationships I have developed through collaboration with faculty

and staff at City College of San Francisco in the Health Education and Community Studies

Department and the wonderful people who gave their time and energy to review my article

numerous times. These relationships developed over the course of working on my CE and I

hope they will continue after I finish my degree.




                                                                                                  41
       The last reward is the contribution I feel that I have made in trying to gain recognition for

community health workers. I hope to add my findings to the greater body of knowledge on the

necessity of integrating CHWs and their services into the health system.




                                                                                                  42
References

1.    Rosenthal EL. The National Community Health Advisor Study: Weaving the Future.
      Policy Research Brief. Tucson, Arizona: University of Arizona; 1998 June 1998.
2.    Zuvekas A, Nolan L, Tumaylle C, Griffin L. Impact of community health workers on
      access, use of services, and patient knowledge and behavior. J Ambul Care Manage
      1999;22(4):33-44.
3.    Keane D, Nielsen C, Dower C. Community Health Workers and Promotores in
      California. San Francisco: UCSF Center for the Health Professions; 2004 September
      2004.
4.    Nemcek MA, Sabatier R. State of evaluation: community health workers. Public Health
      Nurs 2003;20(4):260-70.
5.    IOM. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
      Washington DC: The National Academies Press; 2002.
6.    APHA. Recognition and Support for Community Health Workers' Contributions to
      Meeting our Nation's Health Care Needs. In: American Public Health Association;
      2001:1-3.
7.    Brownstein JN, Bone LR, Dennison CR, Hill MN, Kim MT, Levine DM. Community
      health workers as interventionists in the prevention and control of heart disease and
      stroke. Am J Prev Med 2005;29(5 Suppl 1):128-33.
8.    Oregon Public Health Association CHW position paper. In: Connections: The Center for
      Sustainable Health Outreach; 2003:1-6.
9.    Solomon K, Schindel J, Cherner D, O’Neil E. Defining the Frontline Workforce. In: The
      Robert Wood Johnson Foundation; 2005:1-194.
10.   Advancing Community Health Worker Practice and Utilization. 2006. (Accessed
      February 28th, 2006, at
      http://www.futurehealth.ucsf.edu/nfme/commhealthworkers.html.)
11.   Tsai C. Director of Special Projects and Training, Community Health Works of San
      Francisco. In. San Francisco; 2005:personal communication.
12.   Critical Links: Study Findings and Forum Highlights on the Use of Community Health
      Workers and Interpreters in Minnesota. In: Blue Cross and Blue Shield of Minnesota;
      2003:1-51.
13.   Ballester G. Community Health Workers: Essential to Improving Health in
      Massachusetts. In: Health MDoP, ed.: Health Resources and Services Administration;
      2005:1-19.
14.   Love MB, Gardner K, Legion V. Community health workers: who they are and what they
      do. Health Educ Behav 1997;24(4):510-22.
15.   Cowans S. Bay Area Community Health Worker Study. In: San Francisco State
      University; 2005:1-29.
16.   Trends and Issues in Academic Publishing: A Discussion Paper. 2005. (Accessed April
      3rd, 2006, at http://www.copyright.mq.edu.au/pdf/TrendsAcademPub.pdf.)
17.   Doyle EI, Coggin C, Lanning, Beth. Writing for Publication in Health Education.
      American Journal of Health Studies 2004;19(2):100-9.
18.   Building a Better Literature Review: Reference and Information Sources for I-O
      Psychology. 2001. (Accessed October 17th, 2005, at
      http://siop.org/tip/backissues/TipApr01/07Tubre.htm.)

                                                                                         43
19.   Andrews JO, Felton G, Wewers ME, Heath J. Use of community health workers in
      research with ethnic minority women. J Nurs Scholarsh 2004;36(4):358-65.
20.   Albright A, Satterfield D, Broussard B, et al. Diabetes community health workers.
      Diabetes Educ 2003;29(5):818, 21-4.
21.   Fedder DO, Chang RJ, Curry S, Nichols G. 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.
22.   Gary TL, Batts-Turner M, Bone LR, et al. A randomized controlled trial of the effects of
      nurse case manager and community health worker team interventions in urban African-
      Americans with type 2 diabetes. Control Clin Trials 2004;25(1):53-66.
23.   Community Health Workers/Promotores de Salud: Critical Connections in Communities.
      In; 2005.
24.   Struthers R, Hodge FS, De Cora L, Geishirt-Cantrell B. The experience of native peer
      facilitators in the campaign against type 2 diabetes. J Rural Health 2003;19(2):174-80.
25.   Brown SA, Hanis CL. A community-based, culturally sensitive education and group-
      support intervention for Mexican Americans with NIDDM: a pilot study of efficacy.
      Diabetes Educ 1995;21(3):203-10.
26.   Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse
      case manager and community health worker interventions on risk factors for diabetes-
      related complications in urban African Americans. Prev Med 2003;37(1):23-32.
27.   Bird JA, McPhee SJ, Ha NT, Le B, Davis T, Jenkins CN. Opening pathways to cancer
      screening for Vietnamese-American women: lay health workers hold a key. Prev Med
      1998;27(6):821-9.
28.   Hansen LK, Feigl P, Modiano MR, et al. An educational program to increase cervical and
      breast cancer screening in Hispanic women: a Southwest Oncology Group study. Cancer
      Nurs 2005;28(1):47-53.
29.   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.
30.   Margolis KL, Lurie N, McGovern PG, Tyrrell M, Slater JS. Increasing breast and
      cervical cancer screening in low-income women. J Gen Intern Med 1998;13(8):515-21.
31.   Brownstein JN, Cheal N, Ackermann SP, Bassford TL, Campos-Outcalt D. Breast and
      cervical cancer screening in minority populations: a model for using lay health educators.
      J Cancer Educ 1992;7(4):321-6.
32.   Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes
      Project: a randomized, controlled trial of a community health worker intervention to
      decrease exposure to indoor asthma triggers. Am J Public Health 2005;95(4):652-9.
33.   Takaro TK, Krieger JW, Song L. Effect of environmental interventions to reduce
      exposure to asthma triggers in homes of low-income children in Seattle. J Expo Anal
      Environ Epidemiol 2004;14 Suppl 1:S133-43.
34.   Butz AM, Malveaux FJ, Eggleston P, et al. Use of community health workers with inner-
      city children who have asthma. Clin Pediatr (Phila) 1994;33(3):135-41.
35.   Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The
      impact of a promotora on increasing routine chronic disease prevention among women
      aged 40 and older at the U.S.-Mexico border. Health Educ Behav 2004;31(4 Suppl):18S-
      28S.


                                                                                              44
36.   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.
37.   McQuiston C, Choi-Hevel S, Clawson M. Protegiendo Nuestra Comunidad:
      empowerment participatory education for HIV prevention. J Transcult Nurs
      2001;12(4):275-83.
38.   Morris LA, Ulmer C, Chimnani J. A role for Community HealthCorps members in youth
      HIV/AIDS prevention education. J Sch Health 2003;73(4):138-42.
39.   Allen JK, Scott LB. Alternative models in the delivery of primary and secondary
      prevention programs. J Cardiovasc Nurs 2003;18(2):150-6.
40.   Kim S, Koniak-Griffin D, Flaskerud JH, Guarnero PA. The impact of lay health advisors
      on cardiovascular health promotion: using a community-based participatory approach. J
      Cardiovasc Nurs 2004;19(3):192-9.
41.   Levine DM, Bone LR, Hill MN, et al. The effectiveness of a community/academic health
      center partnership in decreasing the level of blood pressure in an urban African-American
      population. Ethn Dis 2003;13(3):354-61.
42.   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.
43.   Krieger J, Collier C, Song L, Martin D. 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.
44.   Improving the Health and Quality of Life of All People. Center for Disease Control,
      2005. (Accessed March 21st, 2006, at
      http://www.cdc.gov/nccdphp/publications/brochure/brochure.htm.)
45.   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.
46.   Kegler MC, Stern R, Whitecrow-Ollis S, Malcoe LH. Assessing lay health advisor
      activity in an intervention to prevent lead poisoning in Native American children. Health
      Promot Pract 2003;4(2):189-96.
47.   Thomas JC, Eng E, Clark M, Robinson J, Blumenthal C. Lay health advisors: sexually
      transmitted disease prevention through community involvement. Am J Public Health
      1998;88(8):1252-3.
48.   Ramos IN, May M, Ramos KS. Environmental health training of promotoras in colonias
      along the Texas-Mexico border. Am J Public Health 2001;91(4):568-70.
49.   Rodriguez VM, Conway TL, Woodruff SI, Edwards CC. Pilot test of an assessment
      instrument for Latina community health advisors conducting an ETS intervention. J
      Immigr Health 2003;5(3):129-37.
50.   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.
51.   Roman LA, Lindsay JK, Moore JS, Shoemaker AL. Community health workers:
      examining the Helper Therapy principle. Public Health Nurs 1999;16(2):87-95.




                                                                                              45
52.   Tessaro I, Campbell M, O'Meara C, et al. State health department and university
      evaluation of North Carolina's Maternal Outreach Worker Program. Am J Prev Med
      1997;13(6 Suppl):38-44.
53.   Barnes-Boyd C, Fordham Norr K, Nacion KW. Promoting infant health through home
      visiting by a nurse-managed community worker team. Public Health Nurs
      2001;18(4):225-35.
54.   Hans S, Korfmacher J. The Professional Development of Paraprofessionals. Zero to
      Three 2002;23(2):4-8.
55.   Farquhar SA, Michael YL, Wiggins N. Building on leadership and social capital to create
      change in 2 urban communities. Am J Public Health 2005;95(4):596-601.
56.   Wolff M, Young S, Maurana CA. Community advocates in public housing. Am J Public
      Health 2001;91(12):1972-3.
57.   Kim S, Flaskerud JH, Koniak-Griffin D, Dixon EL. Using community-partnered
      participatory research to address health disparities in a Latino community. J Prof Nurs
      2005;21(4):199-209.
58.   Lever M, Moore J. Experience in health promotion with community participation.
      Community Practitioner 2004;77(7):261-4.
59.   FamiliesUSA. Improve Public Programs, Improve Minority Health. In: Making Public
      Programs Work for Communities of Color: An Action Kit for Community Leaders;
      2006:1-7.
60.   Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in
      Health Care. Washington DC: The National Academies Press; 2002.
61.   Love MB, Legion V, Shim JK, Tsai C, Quijano V, Davis C. CHWs get credit: a 10-year
      history of the first college-credit certificate for community health workers in the United
      States. Health Promot Pract 2004;5(4):418-28.
62.   Martin MY. Community health advisors effectively promote cancer screening. Ethn Dis
      2005;15(2 Suppl 2):S14-6.
63.   Altpeter M, Earp JA, Bishop C, Eng E. Lay health advisor activity levels: definitions
      from the field. Health Educ Behav 1999;26(4):495-512.
64.   Hill MN, Bone LR, Butz AM. Enhancing the role of community-health workers in
      research. Image J Nurs Sch 1996;28(3):221-6.
65.   Samuels SE, Adess N, Harper MH, Peacock E, Wyn R, Stone-Francisco S. Allies for
      Quality: Lay Health Workers' Role in Improving Health Care Quality. Oakland:
      California HealthCare Foundation; 2003 November.
66.   Berman PA, Gwatkin DR, Burger SE. Community-based health workers: head start or
      false start towards health for all? Soc Sci Med 1987;25(5):443-59.
67.   Love MB, Gardner K. The Emerging Role of the Community Health Worker in
      California. Sacramento, CA: Center for Health Promotion; 1992.
68.   Earp JA, Flax VL. What lay health advisors do: An evaluation of advisors' activities.
      Cancer Pract 1999;7(1):16-21.
69.   Maurana C, Rodney M. Strategies for Developing a Sucessful Community Health
      Advocate Program. Family and Community Health 2000;23(1):40-9.
70.   Nichols DC, Berrios C, Samar H. Texas' community health workforce: from state health
      promotion policy to community-level practice. Prev Chronic Dis 2005;2 Spec no:A13.
71.   Poss JE. Providing culturally competent care: is there a role for health promoters? Nurs
      Outlook 1999;47(1):30-6.


                                                                                              46
72.   Salber EJ. Where does primary care begin? The health facilitator as a central figure in
      primary care. Isr J Med Sci 1981;17(2-3):100-11.
73.   Swider SM. Outcome effectiveness of community health workers: an integrative
      literature review. Public Health Nurs 2002;19(1):11-20.
74.   Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers:
      integral members of the health care work force. Am J Public Health 1995;85(8 Pt
      1):1055-8.
75.   McElmurry BJ, Park CG, Buseh AG. The nurse-community health advocate team for
      urban immigrant primary health care. J Nurs Scholarsh 2003;35(3):275-81.
76.   Henson K. Writing for Publication: A Controlled Art. Phi Delta Kappan
      2005;86(10):772-81.
77.   Naylor WP, Munoz-Viveros CA. The art of scientific writing: how to get your research
      published! J Contemp Dent Pract 2005;6(2):164-80.
78.   Kliewer MA. Writing it up: a step-by-step guide to publication for beginning
      investigators. AJR Am J Roentgenol 2005;185(3):591-6.
79.   Mee CL. 10 Lessons on Writing for Publication. Clinical Journal of Oncology Nursing
      2001;5(3):1-2.
80.   Economic Inequality and Health. Environmental Research Foundation, 1996. (Accessed
      March 23rd, 2006, at http://home.att.net/~Resurgence/InequalityHealth.htm.)
81.   MacQueen G, Santa-Barbara J. Conflict and Health: Peace Building Through Health
      Initiatives. British Medical Journal 2000;321:293-6.




                                                                                            47
Appendices

Appendix A: Spreadsheet of public health journals

Appendix B: Public health conference schedule

Appendix C: APHA Abstract

Appendix D: CPHA-N Abstract

Appendix E: SOPHE Abstract

Appendix F: NCWE Abstract

Appendix G: Article submitted to the American Journal of Public Health




                                                                         48
49
50
51
52
Appendix B: Public Health Conference Schedule


                             Public Health Conference Schedule
     Conference name                   Conference date        Abstract deadline     Abstract
                                                                                   submitted
American Public Health           November 4th - 7th, 2006    February 13th, 2006
Association (APHA)                                                                   Yes
                                                nd   th              th
Society for Public Health        November 2 - 4 , 2006       April 28 , 2006         Yes
Educators (SOPHE)
California Community             March 15th – 17th, 2006     May 17th, 2005          Yes
College Association for
Occupational Education
(CCCAOE)
California Public Health         March 29th – 30th, 2006     March 22nd, 2006        Yes
Association – North
(CPHA-N)
National Council for             October 21st - 24th, 2006   April 17th, 2006
Workforce Education
(NCWE)




                                                                                           53
Appendix C: American Public Health Association Abstract

Community health worker profiles: A study of employment trends in the Bay Area

This project adds to the growing body of knowledge expanding the recognition of CHWs as an
essential part of the healthcare system. The purpose of this project was to study current and
future employment opportunities for Community Health Workers (CHWs) in four counties of the
Bay Area. CHWs are community members who provide health-related services to primarily low-
income, ethnically diverse communities. The study solicited the participation of employers of
CHWs in San Francisco, San Mateo, Alameda and Contra Costa counties. A stratified random
sample was developed from hospitals, educational institutions, national organizations,
community clinics, public health departments, community-based organizations and health
maintenance organizations, resulting in a sample of 248 organizations. Each organization was
contacted to determine if 1) they employed CHWs and 2) they were available to participate in an
online survey. Of the 248 organizations contacted, 134 stated that they employed CHWs, and
were emailed the survey. The results showed that 2/3 of organizations who responded to the
survey employed CHWs, and that overall there is growth for CHW positions in all sectors,
primarily health departments, community-based organizations and community clinics. The data
profiled a CHW as a women (65%) of color (69%) with either a high school degree (32%) or a
bachelors degree (26%), making less then $35,000 (63%) and receiving health benefits (93%).
Lastly, although there are few structured opportunities for career advancement, education and
on-going training can play a large role in the hiring and advancement of CHWs.

Learning objectives

At the conclusion of the session, the participant (learner) in this session will be able to:
1. Identify key characteristics of Community Health Workers (CHWs) employed in the Bay
Area.
2. Discuss employment trends for CHWs in the Bay Area.
3. List potential educational and training opportunities for the advancement of CHWs employed
in the Bay Area.
4. Identify three employment barriers for employers of CHWs in the Bay Area.




                                                                                             54
Appendix D: California Public Health Association – North Abstract

Community health worker profiles: A study of employment trends in the Bay Area
                                  Sahru Keiser, BA.

This project adds to the growing body of knowledge expanding the recognition of CHWs as an
essential part of the healthcare system. The purpose of this project was to study current and
future employment opportunities for Community Health Workers (CHWs) in four counties of the
Bay Area. CHWs are community members who provide health-related services to primarily low-
income, ethnically diverse communities. The study solicited the participation of employers of
CHWs in San Francisco, San Mateo, Alameda and Contra Costa counties. A stratified random
sample was developed from hospitals, educational institutions, national organizations,
community clinics, public health departments, community-based organizations and health
maintenance organizations, resulting in a sample of 248 organizations. Each organization was
contacted to determine if 1) they employed CHWs and 2) they were available to participate in an
online survey. Of the 248 organizations contacted, 134 stated that they employed CHWs, and
were emailed the survey. The results showed that 2/3 of organizations who responded to the
survey employed CHWs, and that overall there is growth for CHW positions in all sectors,
primarily health departments, community-based organizations and community clinics. The data
profiled a CHW as a women (65%) of color (69%) with either a high school degree (32%) or a
bachelors degree (26%), making less then $35,000 (63%) and receiving health benefits (93%).
Lastly, although there are few structured opportunities for career advancement, education and
on-going training can play a large role in the hiring and advancement of CHWs.




                                                                                             55
Appendix E: Society of Public Health Educators (SOPHE) Abstract

Community health worker profiles: A study of employment trends in the Bay Area

This project adds to the growing body of knowledge expanding the recognition of CHWs as an
essential part of the healthcare system. The purpose of this project was to study current and
future employment opportunities for Community Health Workers (CHWs) in four counties of the
Bay Area. CHWs are community members who provide health-related services to primarily
low-income, ethnically diverse communities. The study solicited the participation of employers
of CHWs in San Francisco, San Mateo, Alameda and Contra Costa counties. A stratified random
sample was developed from hospitals, educational institutions, national organizations,
community clinics, public health departments, community-based organizations and health
maintenance organizations, resulting in a sample of 248 organizations. Each organization was
contacted to determine if 1) they employed CHWs and 2) they were available to participate in an
online survey. Of the 248 organizations contacted, 134 stated that they employed CHWs, and
were emailed the survey. The results showed that 2/3 of organizations that responded to the
survey employed CHWs, and that overall there is growth for CHW positions in all sectors,
primarily health departments, community-based organizations and community clinics. The data
profiled a CHW as a woman (65%) of color (69%) with either a high school degree (32%) or a
bachelor’s degree (26%), making less then $35,000 (63%) and receiving health benefits (93%).
Lastly, although there are few structured opportunities for career advancement, education and
on-going training can play a large role in the hiring and advancement of CHWs.

Learning objectives

At the conclusion of the session, the participant (learner) in this session will be able to:
1. Identify key characteristics of Community Health Workers (CHWs) employed in the Bay
Area.
2. Discuss employment trends for CHWs in the Bay Area.
3. List potential educational and training opportunities for the advancement of CHWs employed
in the Bay Area.
4. Identify three employment barriers for employers of CHWs in the Bay Area.




                                                                                             56
Appendix F: National Council for Workforce Education

Call for Presenters
Deadline for Submissions: April 17, 2006

This completed form must accompany your submission. If your presentation is selected, and any
contact information changes, please notify the NCWE via email at: ncwe@ncwe.org.
Completed applications must be emailed to ncwe@ncwe.org by April 17, 2006.

Date of Submission: 4/17/06

I found out about the Symposium Call For Presentations via:
 Email__X__                          Mail_____                      Website ______
 Other _____           Referral/Colleague_____


PRESENTATION and PRESENTER INFORMATION

Presentation Title: Employment Data and Curriculum Innovations for the Community Health
Workforce: Frontline Workers of the 21st Century
Primary Contact Name: Janey Skinner
Title: Special Projects Consultant
Organization: Regional Health Occupations Resource Center - Interior Bay Region
Address: Community Health Works, 1600 Holloway HSS 301

City/State/Zip: San Francisco, CA 94132                Phone: 415 405 0778      Fax: 415-338-
7948
Email:* jeskinne@ccsf.edu

CO-PRESENTER(S) INFORMATION

Name(s) w/ title(s):
1) Sahru Keiser, Researcher
2) Tim Berthold, Chair, Health Education & Community Health Studies
3) Patricia Perkins, Director

Organization:
1) San Francisco State University, Health Education Dept
2) City College of San Francisco
3) Interior Bay RHORC

Address:
1) 1600 Holloway HSS 301
2) 50 Phelan Avenue Cloud Hall 363
3) 1600 Holloway HSS 301

City/State/Zip

                                                                                           57
1) San Francisco, CA 94132
2) San Francisco, CA 94112
3) San Francisco, CA 94132

Phone:
1) _____ _____
2) (415) 452-5266
3) 415-405-0777

Fax:
1) _____ _____
2) (415) 452-5162
3) 415-338-7948

Email:
1) sahru@sfsu.edu
2) tberthol@ccsf.edu
3) rhorc@sfsu.edu

E-mail will be the primary communication vehicle for conference presenters.

Type of presentation
    Concurrent Breakout Sessions are individual breakouts. At most time periods, there will
        be six sessions. Attendance in each is expected to be between 15 and 50.
   ☐ Pre-Conference Workshop are designed to explore topics in greater depth and often
        involve developing new skills in topics important for success in workforce education.
        Examples may include curriculum development strategies, leadership development,
        environmental scanning, or task analyses. Attendees pay extra to participate in pre-
        conference workshops and expect to leave the session with ideas to implement. The cost
        of materials and refreshments for the session are covered by the registration fee, but
        presenters do not typically receive proceeds from conducting these workshops.
   ☐ Roundtable Discussion are designed as informal discussion sessions. Proposers should
        come with some materials to provoke conversations, including questions to pose to
        generate discussion.

Area of interest (select one below)
    ☐ New Roles for Community Colleges
    ☐ Local Impact of Global Economics
     Curriculum Issues and Advancements
    ☐ Collaborations, Alliances, and Partnerships
    ☐ Developing Basic Workplace Skills
    ☐ Transition to College and Career Pathways
    ☐ State and National Policy Issues
    ☐ Other: _____



                                                                                            58
Presentation Elaboration
Description for Program Brochure (maximum 50 words): City College of San Francisco
(CCSF) and its partners surveyed employers of community health workers, a vocation rarely
documented in traditional EWD studies. This session features the survey results and their
application to CCSF's innovative array of certificates for community health workers, including a
new Trauma Prevention and Recovery Certificate.

Planned Session Outcomes and Rationale of How Topic is Relevant for Audience:
Outcomes:
1 - Participants will be able to describe at least 3 trends in employment of community health
workers.
2 - Participants will be able to discuss how employer survey data was used to develop specific
enhancements to vocational training.
3 - Participants will be able to relate the diverse forms of community health work to the
vocational training programs responsive to this growing field.

Rationale:
Integrating employment data into the development of vocational programs can be challenging for
EWD professionals, especially in emerging work fields. City College of San Francisco (CCSF)'s
survey of employers of community health workers demonstrated the continued importance of
this field to the nonprofit and public sector workforces, as well as their specific needs for training
and professional development. Community colleges have an opportunity to support new career
pathways for community health workers, many of whom are nontraditional students. CCSF has
been an innovator in the development of certificate programs in community health work, as well
as the articulation of this training into an academic major for those seeking a Bachelor's degree.
CCSF is now offering among the first public health/community health Associate's degree majors
in the country.

Presentation Strategy
This presentation will include a PowerPoint presentation of survey findings and their specific
application to vocational programs at CCSF including the new Trauma Prevention and Recovery
Certificate, the new Health Education and Community Health Studies major, and enhancements
to an existing Community Health Worker certificate. The presenters will engage the audience
with prepared questions to generate discussion of how this data could be applied to their
programs.

CRITICAL DATES TO REMEMBER:

   ☐ Proposal Due                                                     Monday, April 17, 2006
   ☐ Notification to selected participants                            Thursday, June 1, 2006

Once presenters have been selected, NCWE will communicate with the primary contact
regarding audio-visual support.




                                                                                                   59
Appendix G: Article submitted to the American Journal of Public Health



ABSTRACT
Objectives: To examine current and future employment opportunities for Community Health
Workers (CHWs) in four counties of the San Francisco Bay Area and compare the results to
similar labor market studies conducted over the last ten years.

Methods: A stratified random sample was developed of employers from various public health
organizations, resulting in a sample of 248 organizations.

Results: Two-thirds of organizations that responded to the survey employed CHWs. The data
profiled a typical CHW as a woman (65%), of color (77%), with a high school degree (32%) or a
bachelor’s degree (26%), making less then $35,000 (63%) and receiving health benefits (93%).

Conclusions: Overall, the CHW occupation is growing, but continues to be threatened by a lack
of stable funding and a limited career ladder. These threats are obstacles to CHWs being
integrated more fully into the health system. The observations from this study are similar to
results from four other studies of employment and CHWs over the past ten years. Further, these
observations suggest the increasingly vital role CHWs will play in the future of health care.


ARTICLE
         Community health workers (CHWs) are “trusted and respected community member[s]
who provide informal community-based health-related services and who establish vital links
between community-based health providers and persons in the community.”1 CHWs reflect the
ethnic, linguistic and economic diversity of the communities they serve and work to provide
health promotion, case management and service delivery activities.2 They provide a link between
communities and the health system and are in an ideal position to strengthen the social fabric by
building community and increasing social capital.
         An earlier statewide survey showed that roughly half of CHWs work in clinic settings,
providing wraparound services in healthcare.3 The other half work in community outreach
settings, providing a broad spectrum of services, from healthcare delivery to various public
health functions.3 Most recently, a large national study found that there were 305,200 social and
human service assistants (CHWs) employed in 2002.4
         Although it is difficult to accurately evaluate the activities and impact of CHWs, there is
a sizeable amount of research to suggest that CHW interventions have beneficial effects.5
Specific areas where these effects have been found include: improving access to health services,1,
5, 6
     improving knowledge as a result of health education,7-9 increasing behavior change6, 9-14 and
promoting culturally specific social support.5, 15-17 They have also been shown to strengthen
existing community networks,18-22 7, 23 improve healthcare delivery,24, 25 improve general health
status15, 26-29 and reduce healthcare costs.15, 30-32
         The history of CHWs began in the community health centers that sprang up in the 1960s.
Federal legislation, the Migrant Health Act in 1962 and the Economic Opportunity Act in1964,
were aimed at promoting the use of CHWs in traditionally underserved or economically
disadvantaged populations, such as migrant workers from Mexico, South and Central America;
African Americans; and Native American Indians.30 A considerable body of research over the

                                                                                                 60
last ten years supports the need for integrating CHW services into the standard model of care,
with the goal of effectively decreasing racial and ethnic health disparities.2, 4, 33-39
         As the healthcare system changes to meet the growing needs of ethnically, linguistically
and economically diverse communities, an emerging priority becomes delivering culturally
competent, high quality care at the lowest cost. Employing CHWs appears to be a cost-effective
method of delivering public health care.2 Unfortunately, the growth of the profession has been
slow. Factors such as status and visibility as members of the health profession, as well as a lack
of a common job definition, are two explanations.
         As an example of the status of CHWs, this study describes current and future
employment opportunities for CHWs in four counties of the San Francisco Bay Area. In order to
understand the labor market for CHWs in the Bay Area, the following five questions were
developed:
         1) What are the current and future hiring needs for employers of CHWs?
         2) What are the challenges facing CHWs in obtaining employment?
         3) What are the demographics of CHWs who are currently employed?
         4) In what major fields or areas are CHWs employed?
         5) Who are the organizations and agencies that employ CHWs:
         This article will also discuss how these results compare to similar labor market studies
conducted over the last ten years.

METHODS

Sample
         This study focused on employers of CHWs in the California counties of San Francisco,
San Mateo, Alameda and Contra Costa. A stratified random sample was used with oversampling
in smaller or underrepresented categories of employers. A list of organizations in the four
counties was developed by a) reviewing and updating the sample used in a previous 1997 Labor
Market Study36; b) conducting a thorough search of funding agencies grantees and service
agencies; and c) conducting a comprehensive web-based search, supplementing gaps in
organizations within type of health care provider by county. This method resulted in an eligible
population of 365 organizations, of which 134 eventually agreed to participate in the study.
         The list of organizations was sorted by county and divided into seven categories of health
care providers as follows: 1) health maintenance organizations; 2) hospitals; 3) national
organizations; 4) educational institutions; 5) community-based organizations; 6) public health
departments; and 7) community clinics. Categories that contained less then 30 organizations had
all organizations included in the sample. For categories with more then 30 organizations, a
random sample was drawn. This resulted in a stratified sample of 248 organizations. Each
organization was then contacted by phone and/or email for preliminary screening to determine:
1) if they employed CHWs and 2) if they were available to participate in an online survey.
       Of the 248 organizations identified in the sample, 134 organizations stated that they both
employed CHWs and were available to participate in the survey. The survey was then emailed to
those 134 organizations. Respondents were contacted by phone and/or email three times before
the survey deadline to remind them of the survey and to re-confirm their interest in participating.
Ultimately, 68 organizations participated in the survey.

Labor Market comparison


                                                                                                 61
                   A literature review was conducted to identify labor market studies of CHWs over the past
           ten years. Key words for the search included: labor market, employment, community health
           worker, health educator, lay health advisor, lay health worker, health outreach worker and
           promotore/a. Existing literature reviews on CHWs were also examined, including the South
           Texas Health Research Center - CHW Program Resources, the Texas Department of State Health
           Services - CHW Research Materials Archive and the University of Washington Community
           Campus Partnerships for Health. To complete the review, searching the reference sections of
           other papers was employed.
                   These combined methods produced four labor market study publications; one national,4
           two statewide33, 34 and one local36. Each labor market study was compared to this study, the 2005
           Bay Area Labor Market Study. Similarities and differences were grouped under the five
           following themes: 1) current and future hiring needs; 2) functions and skills of CHWs; 3) profile
           of a CHW; 4) advancement opportunities; and 5) barriers to wider employment.

           Survey creation
                   The online survey was created using surveymonkey.com, which allows the user to create,
           distribute and analyze online surveys. The survey consisted of thirty-nine questions and took the
           average respondent 15 to 20 minutes to complete. Before the final survey was administered, it
           was pre-tested with input from a CHW as well as with feedback from other key stakeholders who
           critiqued the online survey instrument.

           RESULTS

           Current and Future Hiring Needs
                   Fifty-one percent of the 134 organizations that agreed to participate in the email survey,
           or 68 organizations, completed the surveys. Of the 68 respondents, 62% reported employing
           CHWs, 31% reported having no CHWs, 51% planned to hire in the next three years and 7% did
           not respond to that question (see Table 1).

           Table 1 – Hiring of Current and Future CHWs

 Type of Organization          # of        Employ   Do not     Plan to hire    Hiring due     No new   Unknown           No
                           organizations   CHWs     employ    in the next 3      to staff      hires                  response
                            responded                CHWs         years        turnovers
Health Maintenance                     4        2         1                2              0        0         1               1
Organizations
Hospitals                             7         5         2               3              0         1         3               0
National organizations                8         3         4               4              0                   2               1
Educational institutions              4         1         3               1              0         3         0               0
Community-Based                      14         6         8               9              0         4         1               0
Organizations
Public Health                        17        14         1               9              3         3         1               2
Departments
Community clinics                    14        11         2               5              1         3         2               1
Totals                               63        42        21              33              4        14        10               5


                  Table 1 shows that the need for CHWs is growing only slowly. For example, thirty-three
           organizations projected a total need for only 121 new CHW positions (averaging 3.6 per
           organization) over the next three years. Four of the organizations projected replacement hiring of
           CHW staff due to expected turnover. Fourteen organizations were projecting no need for CHWs.

                                                                                                                 62
        Funding for CHWs is less than stable across organizations, with forty-eight organizations
stating that over half (64.3%) of the full- and part-time CHW positions were solely supported by
grant funding. Only twenty-three organizations (43%) stated that they considered funding for
their full- and part-time CHWs stable. Sixteen (23%) stated that they considered CHW funding
to be neither stable nor unstable.
        Recruiting CHWs at many organizations occurs through a variety of mechanisms.
Employers recruit new workers for open positions primarily by using the Internet (64%), sending
announcements to established CHW networks (57%) and/or promoting from within (53%).
Recruitment from the City College of San Francisco’s (CCSF) vocational certificate programs
has been disappointing: only 16 organizations (24%) stated that they recruited from CCSF’s
CHW program.

Challenges in Employing CHWs
        Respondents were asked to identify: 1) important skills for CHWs to possess; 2) the
difficulty of finding CHWs with those important skills; and 3) the priority of tasks given to
CHWs employed at their organization (Table 2). Responses to these questions, found that
communication and conflict resolution skills are considered very important—using them
comprised about half of a CHWs time at work—but these skills were very to moderately difficult
to find. Organizations also reported that an employee having a vocational or CHW certificate
was very important, yet it was very to moderately difficult to find candidates with a certificate
(see Table 2). The ability to document work and write reports was listed as the most important
task priority for CHWs, but this skill was found to be very or moderately difficult to find by
about two-thirds (67%) of the organizations.

Table 2 – Important Hiring Factors

            Factors/Skills                  Very       Very to Moderately    Slightly       Task
                                          Important          Difficult       Difficult    Priority
 Communication & conflict resolution     75% (42/56)           65% (31/48)                 50% (23)
                                                                                          Less than
                                                                                             ½ time
 Self-management skills (i.e. is         78% (43/55)          57% (29/51)
 flexible, mature, hard-working, etc.)
 Ability to document work and write      43% (24/56)          67% (35/52)                  55% (26)
 clear reports                                                                            Less than
                                                                                             ½ time
 Multi-cultural competence               71% (40/56)                             39%
                                                                               (20/51)
 Bilingual/Bi-cultural competence        67% (37/55)                             41%       49% (23)
                                                                               (21/51)    Less than
                                                                                             ½ time
 Knowledge of the community              61% (34/56)                             42%
                                                                               (21/50)
 Community outreach skills               57% (32/56)                             49%      36% (17)
                                                                               (25/51)   Most of the
                                                                                               time
 A vocational certificate (such as a     36% (20/55)          57% (25/44)
 CHW certificate)


        When respondents were asked about advancement opportunities for CHWs, 30
respondents (59%) stated that there were some advancement opportunities for CHWs employed
by their organization. Of those, only about 13 described a structured career ladder or series in

                                                                                                       63
place at their organization that allowed entry-level CHWs to advance. Some respondents stated
that additional education and training also played a role in CHWs advancement within
organizations. Whereas limited opportunities for promotion was presented by respondents as a
challenge to hiring CHWs (28%), the biggest challenge reported related to budget constraints
(76%).

Demographics of CHWs
        Organizations were asked to describe their CHWs characteristics in terms of pay level,
health benefits, educational preparation, ethnicity and gender. Figure 1 shows that 14
respondents (33%) stated that CHWs employed at their organization made less than $30,000
annually, 13 (30%) reported between $30,000 and $35,000 annually and 16 (37%) stated that
CHWs made more than $35,000 annually. An overwhelming majority of the full-time CHWs
(93%) were receiving health benefits. Of the employed CHWs at various organizations, about
32% had only a high school degree, about 26% had a bachelor’s degree, about 18% had an
associate’s degree, about 13% had a graduate degree, about 8% had a CHW certificate and about
4% had no degree.

  Figure 1: Salary Range for Employed CHWs           Figure 2: Demographics of Employed CHWs

                                             <$20K   Multi-Racial
                                              7.0%   2.2%
   > $40K                            $20,001-$25K    Asian/Pacific Island          African American
   18.6%                                      7.0%   17.6%                                     24.0%


                                     $25,001-$30K
                                                                                Amer Indian/Ala skan
                                             18.6%
   $35,001-$40K                                                                                 2.0%
   18.6%

                                                     Latino/a                                  White
                                                     31.7%
                                                                                               22.4%
                                     $30,001-$35K
                                             30.2%




       The racial and ethnic diversity of CHWs at surveyed organization was: 31.7%
Latino/Latina, 24 % African-American, 22.4% White, 17.6% Asian or Pacific Islander, 2.2%
Multi-Racial and 2.0% American Indian and/or Alaska Native (see Figure 2). The majority of
CHWs were female (65.31%).

Major Fields/Areas
        In order to get a sense of where CHWs are working, survey participants were asked the
percentage of time the CHWs employed by their agencies spent in specified topical areas. About
half of the time CHWs were working on projects that included one or more of the following
topical areas: alcohol and drug abuse, tobacco prevention, nutrition, HIV/AIDS/STIs/Hepatitis,
violence prevention and chronic disease. By contrast, the areas seldom addressed by CHWs
included: re-entry services for ex-offenders, geriatric/aging services, home health care and
supporting environmental justice.




                                                                                                       64
Populations Served by CHWs
       Organizations employing CHWs described serving various populations including:
Women (73%), Youth/Children (61%), Men (59%) and Immigrants (58%). The topical areas in
which they served these populations included: Nutrition (55%), Youth (55%),
HIV/AIDS/STIs/Hepatitis (47%) and Violence Prevention (47%). Forty-four of 68 organizations
were providing these services at the county level and 35% at the city/municipal level.

On-going Training and Education
       Survey participants were asked about specific topics that the local community college
could offer for on-going staff development. There were two topics that respondents said they
would be very likely to send their employees to study: the health of underserved populations
such as transgender, immigrants, incarcerated populations, etc. (49%), and community
organizing (35%). The two topics that respondents said they would be somewhat likely to send
employees to study were: basic research/needs assessment (34%) and services for victims of
violence (30%). Other possible topics suggested by respondents included cultural
competency/understanding of a community (socially, physically, economically) and
communication skills (written, oral, computer).

DISCUSSION

        This study, along with other similar studies, suggests that the community health worker
occupation is growing, albeit slowly. Employment growth seems strongest within county health
departments and Community Based Organizations (CBOs). Though modest, all health
organization sectors are predicting some growth in positions for CHWs.4, 33, 35, 36 A 2005 study
conducted by the Robert Wood Johnson Foundation4 found that “a 49% increase in openings due
to growth [are] projected...for 2012”4 and estimates that nationwide 50,000 jobs for CHWs will
be opening up due to retirement and advancement, and that 200,000 new jobs will be created for
social and human service assistants of all types.4 In Minnesota, a 2003 study found that more
then one-third of survey respondents stated that they were very likely to increase their numbers
of CHWs in the future.33 This slow growth trend is also not new: in 1997, survey respondents36
estimated hiring 263 CHWs over the next three years.36
        Overall, CHWs work in numerous topical areas, for the most part determined by the
agencies’ focus and program funding. A high concentration of CHWs have been shown to be
working in HIV/AIDS with growth predicted in the areas of alcohol/drug abuse and chronic
disease, according to three different labor market studies.33, 35, 36 In 1997, high concentrations of
CHWs were also working in maternal/child health and primary care.36 This current study
identified three additional areas where CHWs are spending about half of their time: 1) tobacco
prevention, 2) nutrition education and 3) violence prevention.35 Despite an environment of
budget cuts, it is notable that Bay Area employers predicted that there would be no decrease of
CHW positions over the next three years.
        In general, the profile of a typical CHW tended to be female, with ethnicity and
educational background trends dependent on location. Although studies nationwide and in
Massachusetts found that CHWs are primarily white (60% and 80% respectively),34 in the Bay
Area over 70% of CHWs are from communities of color.35, 36 Educational levels among CHWs
also differs nationwide. For example, in the Bay Area CHWs are more likely to hold either only
a high school or a bachelors degree whereas in Massachusetts and nationally, CHWs are more


                                                                                                   65
likely to have some form of a degree beyond high school.4, 34 Although education varies among
CHWs nationwide, the CHW position continues to be an entry point for many into the health and
human services field.
         A number of labor market studies confirm that communication and conflict resolution
skills are important core skills for frontline health workers.34-36 In the Bay Area, employers are
finding it very to moderately difficult to find candidates with these skills.35 Personal qualities
such as patience, maturity and persistence were also noted to be very important skills that
employers look for in CHW candidates.33, 35 The essence of community health work is working
on the community level; therefore, employers in three of the labor market studies rated
knowledge of the community that CHWs serve to be important in making hiring decisions.33-35 In
one study it was rated as extremely important by 51% of respondents.33 Of note in this study, but
not noted in other studies, were two skills that were found to be important: 1) the ability to
document work and write clear reports and 2) bilingual/bicultural competency.35
         Having a vocational certificate, such as a CHW certificate, was seen as a valuable asset
by employers and can also be used as an entry into the field.4, 35 Although having a vocational
certificate was important to some employers in the Bay Area, it was reported as difficult to find
qualified applicants possessing one. In contrast, Minnesota employers stated that specialized
training in the CHW role was not as important as other skills.33 Although these skills make for an
appealing job candidate, once employed, very few employers all over the country offer
advancement opportunities for CHWs.
         Advancement for CHWs centers on the development of career paths, which will not only
retain qualified and experienced employees, but also have the potential of attracting more people
to the role. Ten years ago, a Bay Area survey found that over half of the employers of CHWs had
a career ladder or series within the CHW classification.36 In the last few years, fewer agencies in
the Bay Area are providing structured career ladders for the CHW position. Ballester34 also
found that 76% of CHWs in Massachusetts reported that there is no formal career ladder at their
organization, and that the only opportunity for advancement was to build skills and take on
increased levels of responsibility within their current position.34 Although advancement for
CHWs is important, concentrated efforts to develop systems to sustain CHW programs are also
needed.
         A 1997 regional survey found that budget constraints were the overwhelming reason that
CHWs were not used on a wider basis.36 Recently, this current study, along with three others,
confirmed that the wider employment of CHWs continues to be slowed due to unstable funding.4,
33, 34
       The Robert Wood Johnson Foundation found that due to the “patchwork nature of funding”
for CHW positions, job security and high attrition rates are a critical concern nationwide.4 In
Minnesota, over 80% of surveyed organizations use government grants to fund CHW positions,
which are neither adequate nor stable.33 Lastly, in Massachusetts, unpredictable funding impacts
job security, with 77% of surveyed CHWs unsure of the security of their job due to unstable
funding.34 For these reasons, solving sustainability issues would be the single most important
way to consolidate and grow the field.
         Although CHW programs have been around since the 1960’s, an additional barrier
continues to be the lack of a unified title to describe this worker. Three of the labor market
studies found that there were a myriad of job titles that fell under the CHW “umbrella,” with
different organizations using different job titles.34-36 Not only does the lack of a standard title
limit the visibility and perhaps wider use of CHWs, but it can also lead to incorrect identification
of CHWs and underestimations of total CHWs employed.38


                                                                                                 66
        CHWs are a key component of a well-developed health safety net, helping to promote
healthy behaviors and providing access to appropriate preventative services. With over 75% of
the healthcare budget in the US being spent on chronic disease,41 encouraging self-management
and prevention activities can help bring that cost down. Cost containment, as well as quality
improvements, are important aspects of the current healthcare system, a system that has moved
to a more managed care model.

Limitations
        The study had several limitations. First, the method used to enumerate the sample did not
produce a complete list of all potential agencies that employ CHWs in all four counties. San
Francisco was the closest to a complete sample, based on the existence of numerous established
networks of public health and social services agencies that were not found in the other four
counties. The sample relied on funding sources and the Internet, which resulted in an incomplete
sample for the three other counties. Also, the inclusion of all organizations in some categories
could have led to their over representation in the sample.
        Secondly, the study used an online survey that was self-administered, which has a lower
response rate and more missing data due to respondents skipping questions. To increase the
response rate, each agency was called and the staff person who hires and/or supervises CHWs for
their agency was identified. Also, each potential participant was reminded of the survey three
times by email and phone before the survey deadline.
        Lastly, the size of the sample was small and limited to four counties of the Bay Area.
Therefore the results represent the organizations that responded and completed the survey, and
may not be able to be generalized to the other counties of the Bay Area or California.

Conclusion
         Overall, recent studies suggest that the CHW occupation is growing in numbers.
However, the lack of stable funding and structured career paths continues to impede the
complete integration of CHWs into the health system. Developing structured career paths for
CHWs will not only retain qualified employees but can attract new people to the field.
Concurrently, it continues to be important that funding sources be developed that allow
organizations to institutionalize their CHW programs and safeguard them from unstable grant
funding.
         Stable and secure CHW interventions are a crucial component in building a healthcare
system that is responsive to and cost effective for the entire population. A more responsive
healthcare system, which uses CHWs to increase access to health services, unites communities
and strengthens the social fabric. A healthcare system that is accessible to all promotes respect of
the individual while at the same time meets the communities’ needs.42
         With a complex health care crisis facing the nation, CHWs can be a key element in
preventing the failure of our healthcare system. In order for CHWs to be effective in heading off
this “train wreck”, we need to focus on making system-wide changes that allow us to move
forward and address these issues that continue to plague the CHW occupation.

_____________________________________________________________________________
About the Author
Sahru Keiser is in the Master of Public Health program in the Department of Health Education at
San Francisco State University. Requests for reprints should be emailed to sahru@sfsu.edu.


                                                                                                  67
Acknowledgements
Support for this study was provided by grants from the Economic and Workforce Development
division of California Community Colleges Chancellors Office (04-307-011 and 05-307-011), to
the Regional Health Occupations Resource Center Region IV, a project of Community Health
Works (San Francisco State University and City College of San Francisco). This study was
conducted as part of the San Francisco State University (SFSU) Master in Public Health Field
Internship in collaboration with the Public Research Institute of SFSU. The author would also
like to thank, Tim Berthold and Janey Skinner for their assistance with the survey design and
data interpretation, Patricia Perkins for her assistance in dissemination through the Interior Bay
Area Regional Health Occupations Resource Center, a project of Community Health Works,
Vicki Legion for her insightful feedback on the article, Mary Beth Love and Rick Harvey for
their academic guidance and review of the article, John Rogers for his guidance with data
analysis, Len Finocchio for his helpful feedback on the article and Maya Mirsky for her editorial
assistance.

Human Subject Protection
No protocol approval was needed for this study.

References
1.        Zuvekas A, Nolan L, Tumaylle C, Griffin L. Impact of community health workers on access, use of
services, and patient knowledge and behavior. J Ambul Care Manage 1999;22(4):33-44.
2.        Keane D, Nielsen C, Dower C. Community Health Workers and Promotores in California. San Francisco:
UCSF Center for the Health Professions; 2004 September 2004.
3.        Love MB, Gardner K. The Emerging Role of the Community Health Worker in California. Sacramento,
CA: Center for Health Promotion; 1992.
4.        Solomon K, Schindel J, Cherner D, O’Neil E. Defining the Frontline Workforce. In: The Robert Wood
Johnson Foundation; 2005:1-194.
5.        Andrews JO, Felton G, Wewers ME, Heath J. Use of community health workers in research with ethnic
minority women. J Nurs Scholarsh 2004;36(4):358-65.
6.        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.
7.        Brown SA, Hanis CL. A community-based, culturally sensitive education and group-support intervention
for Mexican Americans with NIDDM: a pilot study of efficacy. Diabetes Educ 1995;21(3):203-10.
8.        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.
9.        Bird JA, McPhee SJ, Ha NT, Le B, Davis T, Jenkins CN. Opening pathways to cancer screening for
Vietnamese-American women: lay health workers hold a key. Prev Med 1998;27(6):821-9.
10.       Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora
on increasing routine chronic disease prevention among women aged 40 and older at the U.S.-Mexico border. Health
Educ Behav 2004;31(4 Suppl):18S-28S.
11.       Hansen LK, Feigl P, Modiano MR, et al. An educational program to increase cervical and breast cancer
screening in Hispanic women: a Southwest Oncology Group study. Cancer Nurs 2005;28(1):47-53.
12.       Krieger J, Collier C, Song L, Martin D. 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.
13.       Takaro TK, Krieger JW, Song L. Effect of environmental interventions to reduce exposure to asthma
triggers in homes of low-income children in Seattle. J Expo Anal Environ Epidemiol 2004;14 Suppl 1:S133-43.
14.       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.
15.       Barnes-Boyd C, Fordham Norr K, Nacion KW. Promoting infant health through home visiting by a nurse-
managed community worker team. Public Health Nurs 2001;18(4):225-35.


                                                                                                              68
16.       Martin MY. Community health advisors effectively promote cancer screening. Ethn Dis 2005;15(2 Suppl
2):S14-6.
17.       Tessaro I, Campbell M, O'Meara C, et al. State health department and university evaluation of North
Carolina's Maternal Outreach Worker Program. Am J Prev Med 1997;13(6 Suppl):38-44.
18.       Albright A, Satterfield D, Broussard B, et al. Diabetes community health workers. Diabetes Educ
2003;29(5):818, 21-4.
19.       Hill MN, Bone LR, Butz AM. Enhancing the role of community-health workers in research. Image J Nurs
Sch 1996;28(3):221-6.
20.       Farquhar SA, Michael YL, Wiggins N. Building on leadership and social capital to create change in 2
urban communities. Am J Public Health 2005;95(4):596-601.
21.       Thomas JC, Eng E, Clark M, Robinson J, Blumenthal C. Lay health advisors: sexually transmitted disease
prevention through community involvement. Am J Public Health 1998;88(8):1252-3.
22.       Kim S, Koniak-Griffin D, Flaskerud JH, Guarnero PA. The impact of lay health advisors on cardiovascular
health promotion: using a community-based participatory approach. J Cardiovasc Nurs 2004;19(3):192-9.
23.       Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Washington DC: The National Academies Press; 2002.
24.       Butz AM, Malveaux FJ, Eggleston P, et al. Use of community health workers with inner-city children who
have asthma. Clin Pediatr (Phila) 1994;33(3):135-41.
25.       Margolis KL, Lurie N, McGovern PG, Tyrrell M, Slater JS. Increasing breast and cervical cancer screening
in low-income women. J Gen Intern Med 1998;13(8):515-21.
26.       Levine DM, Bone LR, Hill MN, et al. The effectiveness of a community/academic health center partnership
in decreasing the level of blood pressure in an urban African-American population. Ethn Dis 2003;13(3):354-61.
27.       Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse case manager and
community health worker interventions on risk factors for diabetes-related complications in urban African
Americans. Prev Med 2003;37(1):23-32.
28.       Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a
randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma
triggers. Am J Public Health 2005;95(4):652-9.
29.       Allen JK, Scott LB. Alternative models in the delivery of primary and secondary prevention programs. J
Cardiovasc Nurs 2003;18(2):150-6.
30.       Nemcek MA, Sabatier R. State of evaluation: community health workers. Public Health Nurs
2003;20(4):260-70.
31.       Berman PA, Gwatkin DR, Burger SE. Community-based health workers: head start or false start towards
health for all? Soc Sci Med 1987;25(5):443-59.
32.       Fedder DO, Chang RJ, Curry S, Nichols G. 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.
33.       Critical Links: Study Findings and Forum Highlights on the Use of Community Health Workers and
Interpreters in Minnesota. In: Blue Cross and Blue Shield of Minnesota; 2003:1-51.
34.       Ballester G. Community Health Workers: Essential to Improving Health in Massachusetts. In: Health
MDoP, ed.: Health Resources and Services Administration; 2005:1-19.
35.       Cowans S. Bay Area Community Health Worker Study. In: San Francisco State University; 2005:1-29.
36.       Love MB, Gardner K, Legion V. Community Health Workers: Who They Are and What They Do. Health
Educ Behav 1997;24(4):510-22.
37.       Advancing Community Health Worker Practice and Utilization. 2006. (Accessed February 28th, 2006, at
http://www.futurehealth.ucsf.edu/nfme/commhealthworkers.html.)
38.       Rosenthal EL. The National Community Health Advisor Study: Weaving the Future. Policy Research
Brief. Tucson, Arizona: University of Arizona; 1998 June 1998.
39.       Tsai C. Director of Special Projects and Training, Community Health Works of San Francisco. In. San
Francisco; 2005:personal communication.
40.       Building a Better Literature Review: Reference and Information Sources for I-O Psychology. 2001.
(Accessed October 17th, 2005, at http://siop.org/tip/backissues/TipApr01/07Tubre.htm.)
41.       Improving the Health and Quality of Life of All People. Center for Disease Control, 2005. (Accessed
March 21st, 2006, at http://www.cdc.gov/nccdphp/publications/brochure/brochure.htm.)
42.       MacQueen G, Santa-Barbara J. Conflict and Health: Peace Building Through Health Initiatives. British
Medical Journal 2000;321:293-6.


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