Facts of Life

Facts of Life:
Issue Briefing for Health Reporters
Vol. 12, No. 3
March 2007

Community Health Workers: Homegrown Care

The Issue

The Facts

Training Community Health Workers

Expert Sources

References

The Issue:

Community health workers deliver health information, support and other service to neighborhoods where traditional health care falls short. Also called lay health workers, promotores and promotoras are usually volunteers who live in the communities they serve. 1 In the United States, most lay helpers work exclusively in areas challenged by ethnic and economic health disparities and poor access to care. But internationally community health workers have been an integral part of the wider health system for nearly a century.

Outreach and Rapport

The rapport between promotoras and their neighbors may be the greatest strength of community health worker programs. Now, that success has attracted the attention of medical professionals who want to expand the benefits beyond the neighborhood. Traditionally promotoras have had no formal ties to the medical system, but now some well-established programs in the Southwest receive funding from national health maintenance organizations. 2 Researchers have noted an emerging tension between community health workers who want to remain tightly focused on their own communities and the larger-scale ambitions of their supporting institutions.

Expanding Services

Researchers want to know if these growing programs can expand beyond underserved communities. Susan Swider, Ph.D., a registered nurse with Rush University Medical Center in Chicago, says the workers’ future depends on their effectiveness: “For chronic illnesses and behavior change, if they can take the time and have something in common with their listeners, community health workers may have broader applicability.”

The Facts:

· A 2002 research review found that community health worker programs were most effective at increasing access to care, especially in underserved populations. ³

· A 2004 systematic review found that community health workers could improve access to health services among ethnic minority women. ⁴

· A 2006 systematic review of the effectiveness of community health workers for people with diabetes found that the care could improve patients’ knowledge of the disease. ⁵

· A national survey found that state certification of community health worker programs made it easier to obtain Medicaid reimbursement for these services. ⁶

· An analysis of a Denver-area community health worker program serving almost 600 men found that the program saved nearly $96,000 annually in uncompensated public health costs. ⁷

· Community health workers helped older Latina women eat more fruits and vegetables daily than their counterparts who did not see a community health worker, according to a 2004 preventive health study. ⁸

· A program that included church-based education and community health worker outreach did not significantly increase breast cancer screening rates among Colorado Latinas with Medicaid. ⁹

· Latino farm workers were more likely to use protective eyewear when community health workers trained them in its use, according to a 2004 study. ¹⁰

· A four-year community health worker program to improve blood pressure monitoring in a Baltimore neighborhood significantly increased the percentage of participants with controlled blood pressure. ¹¹

· A Baltimore community health worker program serving African-Americans with diabetes helped reduce emergency room visits by 40 percent and Medicaid reimbursements by 27 percent among the patients. ¹²

· A small Canadian study of community health workers trained to reduce falls among their older clients found that the intervention reduced the number of falls by 43 percent in six months. ¹³

· Frequent home visits from a community health worker helped reduce the number of days that low-income children suffered asthma symptoms or needed asthma-related urgent care. ¹⁴

Training Community Health Workers

There are no national standards for training community health workers and only a handful of states have pursued formal standards. For decades, community health workers have been locally recruited and trained. But some program supporters think it may be time for more formal training and certification.

Right now, “training is very specific to a neighborhood and a program and is very inexpensive, but they [the workers] have nothing to take in their hand to say, ‘we have this training,’” says Susan Swider, Ph.D., a registered nurse with Rush University Medical Center in Chicago.

Community health workers deserve — and have been asking for — a certificate program that “they can use as a stepping stone” to further their careers in public health, said Swider, who has done extensive research on the programs. The lack of formal training “leaves people in this bad position with nothing to validate themselves to the outside world. It limits their mobility, they have to keep retraining or re-proving themselves everywhere they go,” she says.

Swider praises community health workers for their hard work and successes in underserved neighborhoods. She said there are many “compelling anecdotes about where they’ve been effective, but it’s actually hard to collect solid data when training is so unstandardized.”

If a program “is going to a funder or a federal or state agency to support their work, they need this data to make their case about continuing these programs,” Swider adds.

Lisa Staten, Ph.D., a professor of anthropology at the University of Arizona, has worked with several promotora programs in mostly Latino populations and finds them “incredibly useful” at providing information and encouraging behavior change in their neighborhoods. She said a move toward more formal certification might “eliminate the interpersonal touch” of a community health worker program.

Instead of seeking out trusted community members, some programs now “recruit people by advertisement and drive them through very scripted kind of activities, losing the interpersonal skills and personal level of comfort” that comes with a homegrown promotora, Staten says.

Swider and Staten both say that money, especially Medicaid reimbursement for community health worker services, is a driving force behind training standards. But any certification program “should be developed with people who have worked with promotoras and know about the personal traits that are very important,” Staten says.

Swider agrees, saying that the strength of community health workers lies in their ability to communicate easily with the populations they serve: “Health workers represent communities that have been marginalized and are very passionate about that. Putting them in white coats and clipboards starts to put a little social distance in there.”

Community health workers are “underrecognized assets” that allow neighborhoods “to utilize strength from within,” Staten says.

Expert Sources: