A History of Community Health Workers:
Assisting the Underserved

---

Few people outside the health services field know about Community Health Workers. Yet thousands of CHWs are working in their communities every day. Through education, advocacy and outreach, CHWs help their neighbors navigate the healthcare bureaucracy and social system maze by breaking down the barriers to needed care. In multi-ethnic and underserved communities, CHWs build trusting relationships and play a significant role in helping to uncover and possibly reduce racial and ethnic healthcare disparities.

Defined

The title community health worker can apply to a number of supporting occupations in the health services field. Officially, the U.S. Department of Health and Human Services defines CHWs as:

…lay members of communities who work either for pay or as volunteers in association with the local healthcare system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. They have been identified by many titles such as community health advisors, lay health advocates…outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs offer interpretation and translation services, provide culturally appropriate health education and information, assist people in receiving the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening.

Serving worldwide

CHWs are more commonly found in other countries, where they are often chosen by their communities. In Africa, Brazil and Iran, for instance, CHWs provide a critical link to health care in underserved communities. The training varies by country. CHWs can help deliver babies, or offer vaccinations and limited medical evaluations or treatment. They are credited in those countries with lowering infant mortality rates and deaths from preventable conditions such as diarrhea.

In the United States, CHWs are not as entrenched in the healthcare system as they are in those other countries. It wasn't until the 1960s that a CHW work force began emerging in the U.S. Because their duties and titles vary, an exact number is unknown, although Health and Human Services estimates that in the year 2000 there were 86,000 CHWs in the U.S., including as many as 5,000 in Florida. That number has been growing as their acceptance as a legitimate part of the healthcare system gains ground. Over the past decade, several states have passed CHW certification legislation and a federal patient navigator bill was signed into law providing grant funding for CHWs. The American Public Health Association maintains a special interest group of CHWs within the association that advocates for CHWs to be recognized and properly compensated health workers. There is also a National Association of Community Health Workers, which is developing the field as a potential career path. However, much work remains to be done in the U.S. to make the case for hiring CHWs as part of the integrated service delivery teams of community health centers and hospitals.

Training and specializations

When CHWs are hired by community health centers, public health departments or hospitals, the institution often pays for their training. A 2007 study of CHWs for the U.S. Department of Health and Human Services identified five prevailing models of care engaging CHWs:

• Member of care delivery team. In this model, the CHW was largely subordinate to a lead provider, typically a physician, nurse, or social worker. Tasks were relatively specific and generally delegated by the lead provider.
• Navigator. The navigator role placed greater emphasis on the CHW's capabilities for assisting individuals and families in negotiating increasingly complex service systems and for bolstering clients' confidence when dealing with providers. The navigator model did not necessarily require a high degree of clinical supervision, but it did require a high level of awareness about the healthcare system. The major contribution by CHWs in this model was that of improving access and educating consumers as to the importance of timely use of primary care.
• Screening and health education provider. This model of care has been one of the more common, and was often included in many categorically funded initiatives on specific health conditions such as asthma and diabetes. CHWs taught self-care methods, administered basic screening instruments and took vital signs. CHWs were able to gain access to hard-to-reach populations and were willing to work in neighborhoods or rural areas where other professionals were reluctant to practice. There were concerns, however, about the quality of services and information provided by CHWs, prompting calls for strict evaluation of the CHWs' training and close supervision of their activities.
• Outreach-enrolling-informing agent. "Outreach worker" was a common job title for CHWs, and it addressed the need of many programs to reach individuals and families eligible for benefits or services and persuade them to apply for help or come to a provider location for care.
• Organizer. This model of care more often involved volunteer CHWs who became active in a community over a specific health issue, promoting self-directed change and community development. The models listed were not always mutually exclusive and the list was compiled with the intent of integrating several but not all of the existing classification schemes.However, there remains no standard nationwide CHW training. According to the 2007 study for Health and Human Services, "Generally, the occupation of CHW has not been viewed as a career, because CHWs have positions that are often short-term, low paid, and lack recognition by other professionals." The study found an average CHW wage of $13 an hour.

Connecting people

Beyond the medical assistance provided, the greatest asset CHWs provide is their connection to the communities they serve. They reach out directly to residents, sometimes traveling door to door. For the millions of uninsured people who lack a regular source of health care, CHWs can help identify those eligible for public benefits.For those ineligible, CHWs can direct them to community health centers with sliding fee scales. After getting them to the clinic, CHWs can help patients navigate the complex system of care and advocate for their health needs.In this way, CHWs become an indispensable ally for people in low-income communities who may be vulnerable or marginalized because of language, cultural, or financial and geographic barriers.

For more information on Community Health Workers, contact Dr. Leda Perez, Vice President of Health Initiatives for the Collins Center, at lperez@collinscenter.org.