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Community health workers (CHWs) are increasingly being incorporated into health programs because they are assumed to effectively deliver health messages in a culturally relevant manner to disenfranchised communities. Nevertheless, the role of CHWs—who they are, what they do, and how they do it—is tremendously varied. This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs, and translating research into practice. We discuss some of these challenges and provide examples from our experience working with CHWs. We call for future research to identify of the “core elements” of effective CHW programs that improve the health and well-being of disenfranchised communities.
There seems to be a consensus: Community health workers (CHWs) are a good idea. They are a cost effective way to promote health and provide some healthcare services to disenfranchised communities. Furthermore, because most CHWs are members of the communities within which they work, they are assumed to deliver health messages in a culturally relevant manner.1–4 Systematic literature reviews of CHW programs worldwide have provided evidence of their effectiveness for certain behaviors and disease categories but evidence is still insufficient to justify general recommendations for policy and practice.4–8
While community educators and healers have existed worldwide for centuries, CHWs, defined as laypersons who serve as liaisons between members of their communities and healthcare providers and services, have existed since the 1940s.6,9 Over time, health program planners’ efforts to collaborate with CHWs have waxed and waned due to factors such as economic need or healthcare labor shortages.9,10 In the U.S. since the 1980s, health program planners have increasingly collaborated with CHWs to deliver various types of health promotion programs.9,11 With this increase, it has become undoubtedly clear that the role of CHWs today—who they are, what they do, and how they do it—is tremendously varied.10 This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs and to translate that research and evidence into practice.
To ensure that planners integrate CHWs into programs effectively, researchers must seek clarity about the following issues: What problems arise due to the variability surrounding who CHWs are and what they do? How can we evaluate CHW programs to better document their effectiveness? And ultimately, how can we elucidate the core elements of CHW programs so that effective programs can be adopted and implemented in other settings? The remainder of this commentary explores these issues and provides some examples from the authors’ firsthand experience as academic researchers who collaborate primarily with promotores (CHWs for Latino populations).
CHWs are described using several different terms, including: lay health advisors, patient navigators, promotores (CHWs who work primarily with Latinos), outreach workers, peer leaders, peer educators, community health advocates, etc. The diversity of names reflects the different types of roles, or even opposing roles, CHWs are expected to play. For example, the word “lay” in lay health advisors suggests that CHWs are not “professionals” nor have they acquired “expert” knowledge that would set them apart from an ordinary person. The term “patient navigators” implies that the CHWs are embedded within a health care system to the extent that they can help link patients to appropriate care. “Peer leaders” suggests that there is a commonality between the CHWs and their clients, and that they have some leadership characteristics that motivate community members to model or adhere to their recommendations. The term “health advocate” implies that CHWs play an activist role within their community and that their work is related to the larger struggle for social justice for disenfranchised communities. The differences in roles implied by these terms are more than simple semantics; they imply skills and training that would likely vary considerably.
The idea that CHWs are most effective when they share the culture of the populations they serve has important implications for the ways program planners expect CHWs to function and how they are trained.4,6,12–14 Many planners assume that if CHWs share (or, at the very least, understand) the culture of the community member with whom they are interacting, then they will be better able to: tailor health messages; understand the underlying or unspoken reasons that person might adopt or reject recommended behaviors; and act as plausible role models. Nevertheless, important questions remain: What exactly is shared culture? How does it influence CHW program effectiveness? How can planners consistently and appropriately integrate it into program design and training?
Researchers argue that “culture” is more complex than simply sharing language and ethnicity and have expressed the need for programs founded upon a rich and nuanced understanding of culture.15 Culture, “the patterned processes of people making sense of their world”16, is embedded in social context, “the sociocultural forces that shape people’s day-to-day experiences,” and is determined by multiple levels of influence (structural, historic, environmental, local, and individual.17
It is unclear which elements of culture and social context should be shared for CHWs to be effective. It may be that being able to speak the same language or dialect is enough to ensure program effectiveness. On the other hand, there may be unconscious and unspoken understandings between peoples of the same culture that go beyond language that are at play. For example, it may be that Latino CHWs (promotores) in sites with little diversity among Latino populations are more likely to share the culture of their fellow community members, but in large, diverse cities such as Los Angeles, Houston, Chicago, or New York that include subpopulations of Latinos of different cultural backgrounds and influenced by different forces of social context, these assumptions must be questioned.18 These subpopulations may originate from many different countries; have different immigration patterns; levels of acculturation, socio-economic status, etc.18 To design effective health programs, researchers must fully explore how the complex forces of social context and culture play into CHW effectiveness. Further, it should be determined how shared culture differs in importance for programs that address different health issues and different communities.
CHWs work in many different settings, deliver programs to a varying number of people at one or more times, and use a diverse set of tools, all of which influence what they do.1,19–24 CHWs work in public hospitals; community clinics; cancer centers; religiously affiliated community centers, etc. While they can work inside formal and established centers of health care, they are also known for neighborhood outreach, i.e. interacting with community members in homes, workplaces, or churches. Despite this diversity of settings, program planners often assume that CHWs function similarly in all sites. This may not be the case and it is important to take into account the fact that different settings are populated by different people whose health education needs, time available, predisposition to receive health information, and adherence to health messages may differ dramatically. An individual who has access to primary care providers may have very different health-seeking practices than one who does not. There is little evidence on the comparative effectiveness of CHW programs that deliver health education to people in their own homes as compared to clinical settings. Similarly, it is unclear if program effectiveness differs when CHWs work with groups of people (such as families or neighbors) compared to individuals.6 Some research shows that the answers to these questions might depend upon cultural preferences for health communication.25–29
A complicating factor in research with CHWs is that there is little consensus about who or what CHWs really are. Are they community activists engaging in mutually constitutive dialogues with their community members or are they a mere delivery mechanism for health programs?9,30 Not all program planners are clear about which role they expect CHWs to take and existing recommendations for practice do not necessarily provide guidance. For example, the Guide to Community Preventive Services provides recommendations for increasing certain cancer prevention interventions based on a systematic review of the literature. In one review designed to provide guidance about the effectiveness of one-on-one interventions, reviewers classified CHWs programs with other one-on-one programs delivered by clinic-based health care providers.30 This classification, (necessary because of the small number of high quality published studies on the effectiveness of CHWs for cancer control) is problematic in that it obfuscates the advocate role of CHWs and excludes CHW programs that are delivered to groups of community members. The consequences of different expectations for CHWs and a lack of understanding of the core elements that make these programs effective may drastically influence program impact. It may be that CHWs who act as community activists are more effective in improving health outcomes of certain populations, but less so in others. Similarly, it may be that didactic strategies are more effective for some populations than others.30 Creating a separate analytical category for CHW programs in systematic reviews could provide more information about the impact of CHWs and under which circumstances and for what behaviors they are most effective. Further, conducting research on cultural preferences for CHW roles and communication styles could illuminate the broad spectrum of roles that CHWs can and should take when working with different populations.
Differences in program delivery affect the quality of the relationship and interaction that CHWs have with community members can vary widely across programs. It can be influenced by things such as the number of interactions and the tools that are used to facilitate the interaction. Some programs provide multiple opportunities for CHWs to interact with community members, while other interventions involve just one meeting.22 In some cases, the community members with whom CHWs interact are part of their immediate social network, in others they are complete strangers. Additionally, multimedia tools, increasingly being used by CHWs, may be a way to enhance communication between CHWs and community members, but use of such tools varies widely. CHWs are often charged with using a wide range of tools ranging from nothing other than their own voice to pamphlets, videos, or advanced multimedia and computer-based interactive technologies to enhance their communication with individuals. Our research comparing low- and high-tech multimedia tools used by promotores suggests that tools can either enhance or hinder promotores efforts.31 It is important to identify what elements of CHW programs enhance the quality of the relationship between CHWs and community members, noting that this may be different for different health behaviors and for different populations.
For evaluation purposes, it is also important to understand how community members themselves recognize and understand CHWs’ role in their own health seeking practices. Our experience suggests that ordinary people may not know what a CHW is and what CHWs are supposed to do. For example, we found that only 61.9% of 341 study participants who received a promotor-delivered intervention in their home answered positively that they had been visited by a promotor in the past 6 months. This suggests that some of our study participants may have thought that the concerned person who visited them to talk about colorectal cancer was just that—a concerned person—or, that they don’t remember being visited by a “CHW” at all. Or, perhaps study participants were unable to differentiate between data collectors and promotores because both asked questions about colorectal cancer screening. Essentially, the concrete categories researchers use to determine program effectiveness might not resonate with the people they want to help, and from whom they rely on for information. Researchers must find a way to measure this accurately in order to ensure findings can inform practice.
Public health practitioners have called for the integration of CHWs in healthcare systems via the creation of formal infrastructures to make CHW programs remain viable in the long-term.11,14,32,33 Indeed, in many states CHWs have formed formal associations, departments of health have initiated components of institutionalization such as instituting credentialing program with required education, training, and certification (See http://www.chw-nec.org/) and state and federal agencies are beginning to enact policy regarding CHWs.32,34 There are valid reasons for this move. Institutionalizing CHWs could help legitimize their role in the healthcare system and ensure some consistency in terms of the quality of care they are able to provide. Additionally, it could provide them with opportunities for education and career advancement. Lessons learned from other healthcare fields (e.g. nursing) that went through similar processes may be useful consider.35
Nevertheless, there are also reasons to be cautious about this movement. For example, the impact of one component of institutionalization, CHW certification, is still unknown, and we suspect that in some cases it could adversely affect them. For example, organizational preferences for hiring certified CHWs is unknown, and whether or not certified CHWs are paid more than those who are not certified is undocumented. Our research in South Texas revealed that some promotores had been certified by the Texas Department of Health and Human Services, some had not, and that some who had been certified chose not to renew their certification despite the fact that they still worked as promotores. The promotores claimed that organizations preferred to hire certified promotores, but that certified promotores were not paid more than those without certification, and that the community members with whom they worked did not care whether they were certified or not. One of the promotoras reported that for her, the value in certification was in the educational opportunities it provided. The consequences of creating such hierarchies among CHWs, and its effects on their efforts should be known before we invest in widespread programmatic changes.
Furthermore, it may not be easy for CHWs to comply with components integral to certification. Whereas community colleges should be commended for creating innovative mechanisms for delivering CHW certification curriculums, the practical matters and costs related to obtaining certification should not be underestimated. It not only costs money to become certified but non-monetary costs such as time away from paid work (as CHWs or other positions—many of the promotores we have collaborated with have worked two or more paying jobs at a time) or costs of childcare may be incurred when CHWs seek certification. Additionally, health program planners and state certification agencies should consider whether it is fair to expect and require CHWs to be able to navigate community college courses for certification, particularly those who are members of underserved and disadvantaged communities for whom access to and integration into formal higher educational systems is difficult and uncommon. Above all, if formal training is to be required, it must be affordable and accessible.
Indeed, institutionalization might alter the very elements of CHWs that make them effective. Witmer, et. al. illuminated some of the “potential risks” in building a formal infrastructure, stating, “While such support can offer financial and other securities, it can also threaten what makes CHWs unique and effective. The strength of the programs appears to be their flexibility to provide innovative solutions and adapt to changing community health needs and circumstances.”36 Beyond flexibility, it may be the very fact that CHWs are not “experts,” i.e. that they most likely do not differ in terms of education, power, or social capital from their clients, that makes them most effective.13 How might making experts out of CHWs who are supposed to be “like” the community members with whom they work change the dynamic of CHW program delivery and interpersonal communication with clients? Public health practitioners should understand how the institutionalization of CHWs could alter the core elements that help them develop quality relationships with community members and, in turn, increase program effectiveness.
Finally, while institutionalizing CHWs may provide new opportunities for women since most CHWs are female1, often those opportunities exist at the lowest level of healthcare professionals in terms of education and, most likely, in terms of pay.37 Essentially, program planners are asking women to do some of the work for low or no remuneration that those more highly trained professionals do not have time for, have no incentive to do, or are not interested in doing. If CHWs are effective and essential, they must be fairly compensated.38,39
Among the points we raise here, we believe that one of the most critical for increasing the effectiveness of CHW programs as well as their adoption and implementation in community settings around the country is the need to understand the core elements of these programs. What are the active ingredients in CHW programs that make them effective (e.g. interpersonal connectedness and rapport, their function as role model or community advocate, the commitment a person feels to comply with promotoras’ recommendations because of cultural norms)? These largely unanswered questions require thoughtful evaluation approaches to address. Ethnographic methods that highlight culture and social context and seek to situate findings in the fabric of daily life and social context are optimal for this pursuit.40,41 We strongly believe that CHWs can help improve the health and overall well-being of disenfranchised, medically underserved communities. Nevertheless, we recognize that research that provides evidence this end must be conducted to elucidate the components or core elements that ensure their effectiveness and ultimately ensure their place in our healthcare system.
The authors express sincere gratitude to all the promotores with whom they have collaborated over time. Dr. Arvey drafted this manuscript and conducted supportive research as a Postdoctoral Fellow in the University of Texas, School of Public Health Cancer Education and Career Development Program –National Cancer Institute/NIH grant R25-CA-57712. The research reported here was generously funded by Centers for Disease Control Prevention Research Center Special Interest Project (SIP 18- U48 DP000057-01) of which Dr. Fernandez was the Principal Investigator. The content is solely the responsibility of the authors and does not necessarily represent the official views of the national Cancer Institute or the National Institutes of Health.
Contributor StatementSarah R. Arvey conceptualized this article and she and Maria E. Fernandez wrote it.
Human Subjects Approval
This research was conducted with the approval of the Committee for the Protection of Human Subjects at the University of Texas – Houston Health Science Center, School of Public Health (HSC-SPH-04-123).
Authors’ disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. In compliance within NIH regulations, I am providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. The final, definitive version of this article is available at http://ajph.aphapublications.org/.