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