This page provides a selected list of current articles from the research literature of interest to stakeholders in the Promotor(a) or Community Health Worker Training and Certification Program. A promotora/community health worker is defined here as a person who, with or without compensation:
provides cultural mediation between their communities and health and human service systems;
provides informal counseling and social support;
provides culturally and linguistically appropriate health education;
advocates for individual and community needs;
assures people get the services they need;
builds individual and community capacity;
or provides referral and follow-up services.
For further information on the following articles contact the Medical and Research Library at email@example.com or call 512-776-7559. For further information on promotoras/es and community health workers in Texas, contact firstname.lastname@example.org, (512) 776-2570 or (512) 776-2624, or visit the Promotor(a) or Community Health Worker Training and Certification Program website, part of the Office of Title V and Family Health, at http://www.dshs.state.tx.us/mch/chw.shtm.
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may also not be accessible to people with disabilities. The links were working at the time they were created.
Selected Current Journal Articles and Reports
[See a more comprehensive bibliography of articles on community health workers.]
Understanding Scope and Competencies: A Contemporary Look at the United States Community Health Worker Field. Progress Report of the Community Health Worker (CHW) Core Consensus (C3) Project: Building National Consensus on CHW Core Roles, Skills, and Qualities. Rosenthal EL, Rush, CH, Allen CG. April 2016 http://files.ctctcdn.com/a907c850501/1c1289f0-88cc-49c3-a238-66def942c147.pdf?ver=1462294723000
CHW-roles and opportunities in healthcare delivery system reform by John e. Snyder, ASPE Issue Brief, January 2016.
Community Health Workers (CHWs) are an emerging group of health professionals that have recently drawn increased national attention because of their potential to deliver cost-effective, high quality, and culturally competent health services within team-based care models. The apparent benefits of integrating CHWs into health care teams seem to depend on context. The strongest evidence of these benefits supports utilizing CHWs to deliver certain specific, high-value, preventive services – focused on reducing risk factors for cardiovascular disease and other chronic conditions – to low-income, minority, or other underserved populations. Despite growing interest in engaging CHWs in national delivery system reform efforts, there are several uncertainties about how to best proceed with this. Questions remain around standardizing CHW training, certification, and licensure; establishing strong economic and other evidence to support their use; and securing reimbursement for their services to ensure financial sustainability of CHW programs. https://aspe.hhs.gov/sites/default/files/pdf/168956/CHWPolicy.pdf
New Map on Community Health Worker Models
This new NASHP map and chart makes it easy for you to find information about various activities related to CHWs in the states. http://www.nashp.org/state-community-health-worker-models/
New Community Health Worker Toolkit
The Division for Heart Disease and Stroke Prevention has compiled evidence-based research that supports the effectiveness of CHWs in a Community Health Worker (CHW) Toolkit. The toolkit also includes information that state health departments can use to train and further build capacity for CHWs in their communities as well as helpful resources that CHWs can use within their communities (http://www.cdc.gov/dhdsp/pubs/chw-toolkit.htm).
Community Health Worker (CHW) Resources
- State Community Health Worker Models (from State Refor(u)m Webinar 2/23/15) https://www.statereforum.org/state-community-health-worker-models
- Community Health Workers (CHWs) Training/Certification Standards Current Status http://www.astho.org/Public-Policy/Public-Health-Law/Scope-of-Practice/CHW-Certification-Standards/
- Strategies for Supporting Expanded Roles for Non-Clinicians on Primary Care Teams, National Academy for State Health Policy http://www.nashp.org/sites/default/files/NOSOLO-new3.pdf
States Implementing Community Health Worker Strategies
This new technical assistance guide summarizes the successful work of organizations as it relates to Domains 3 and 4 (Health Systems Interventions and Community-Clinical Linkages, respectively) of CDC’s State Public Health Actions program (CDC-RFA-DP13-1305). It also offers insights for states that are implementing CHW strategies. Recommendations were developed by compiling interviews with 9 organizations experienced in integrating CHWs into healthcare teams and engaging CHWs in promoting linkages between the health care system and community resources. Additional findings from a review of evidence-based literature are also included.
Albarran CR, Heilemann MV, Koniak-Griffin D. Promotoras as facilitators of change: Latinas' perspectives after participating in a lifestyle behaviour intervention program. J Adv Nurs. 2014 Oct;70(10):2303-13.
Aim: To describe immigrant Latinas' perspectives of a lifestyle behaviour intervention, focusing on their interactions with and perceptions of the promotoras who delivered the program in the USA. Background: Immigrant Latinas in the USA have high obesity rates, which contribute to increased risk for cardiovascular disease and other long-term diseases. Interventions using the promotora model appear to be effective in reducing cardiovascular disease risk by improving dietary habits, physical activity and selected clinical variables among Latinas. However, there has been very limited enquiry into what it is about these interventions and promotoras that facilitates behaviour change, from the perspective of participants. Design: Grounded theory methodology guided the data collection and analysis. Methods: This qualitative study was completed in 2012 in California, after the end of a lifestyle behaviour intervention. Four focus groups and seven one-on-one interviews were conducted with a total of 18 immigrant Latina intervention participants. Results: Women described promotoras as helping them change by motivating them through three interconnected elements: tools, support and knowledge. Latinas viewed their ability to make lifestyle changes as connected with their emotional and psychological health and saw promotoras as counsellors who gave emotional and social support. In this respect, the intervention was emotionally therapeutic for this sample of Latinas, although this was not the original intention of the program. Conclusion: Promotoras gave the backbone of the intervention and were crucial in motivating Latinas to implement lifestyle changes. Future lifestyle behaviour interventions should include a strong component of mental and emotional well-being.
Calderon V, Mejia Y, del Carmen Lara-Muñoz M, et al. Towards the sustainability of information campaigns: training Promotores to increase the psychosis literacy of Spanish-speaking communities. Soc Psychiatry Psychiatr Epidemiol. 2015 Apr;50(4):665-9.
Purpose: To assess the acceptability and efficacy of training community health workers (promotores) in Mexico to both recognize psychosis and to teach others to recognize psychosis. Methods: Two studies were carried out utilizing a single-group design. In Study 1, promotores watched a DVD-based psychosis literacy training. In Study 2, promotores were trained to administer a flip-chart version of the program and they then administered it to community residents. Results: Significant increases in the post-training assessment of psychosis literacy were observed. Conclusion: Promotores can be an important resource in identifying psychosis early and enhancing the sustainability of psychosis literacy information campaigns.
Campbell JD, Brooks M, Hosokawa P, et al. Community health worker home visits for medicaid-enrolled children with asthma: effects on asthma outcomes and costs. Am J Public Health. 2015 Nov;105(11):2366-72.
Objectives: We sought to estimate the return on investment of a streamlined version of an evidence-based community health worker (CHW) asthma home visit program. Methods: We used a randomized parallel group trial of home visits by CHWs to Medicaid-enrolled children with uncontrolled asthma versus usual care. Results: A total of 373 participants enrolled in the study (182 in the intervention group and 191 in the control group, of whom 154 and 179, respectively, completed the study). The intervention group had greater improvements in asthma symptom-free days (2.10 days more over 2 weeks; 95% CI = 1.17, 3.05; P < .001) and caretakers' quality of life (0.43 units more; 95% CI = 0.20, 0.66; P < .001) and a larger reduction in urgent health care utilization events (1.31 events fewer over 12 months; 95% CI = -2.10, -0.52; P = .001). The intervention arm compared with the control arm saved $1340.92 for the $707.04 additional costs invested for the average participant. The return on investment was 1.90. Conclusions: A streamlined CHW asthma home visit program for children with uncontrolled asthma improved health outcomes and yielded a return on investment of 1.90.
Castaneda SF, Giacinto RE, Medeiros EA, Brongiel I, Cardona O, Perez P, Talavera GA. Academic-community partnership to develop a patient-centered breast cancer risk reduction program for Latina primary care patients. J Racial Ethn Health Disparities. 2016 Jun;3(2):189-99.
This collaborative study sought to address Latina breast cancer (BC) disparities by increasing health literacy (HL) in a community health center situated on the US-Mexico border region of San Diego County. An academic-community partnership conducted formative research to develop a culturally tailored promotora-based intervention with 109 individuals. The Spanish language program, entitled Nuestra Cocina: Mesa Buena, Vida Sana (Our Kitchen: Good Table, Healthy Life), included six sessions targeting HL, women's health, BC risk reduction, and patient-provider communication; sessions include cooking demonstrations of recipes with cancer-risk-reducing ingredients. A pilot study with 47 community health center Latina patients was conducted to examine the program's acceptability, feasibility, and ability to impact knowledge and skills. Pre- and post-analyses demonstrated that participants improved their self-reported cancer screening, BC knowledge, daily fruit and vegetable intake, and ability to read a nutrition label (p < 0.05). Results of the pilot study demonstrate the importance of utilizing patient-centered culturally appropriate noninvasive means to educate and empower Latina patients.
Coronado GD, Beresford SA, McLerran D, et al. Multilevel intervention raises Latina participation in mammography screening: findings from ¡Fortaleza Latina! Cancer Epidemiol Biomarkers Prev. 2016 Apr;25(4):584-92.
Background: Breast cancer is the most commonly diagnosed cancer in women in the United States, and Latinas have relatively low rates of screening participation. The Multilevel Intervention to Increase Latina Participation in Mammography Screening study (¡Fortaleza Latina!) sought to assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington who seek care at a safety net health center. Methods: The study enrolled 536 Latinas ages 42 to 74 who had a primary care clinic visit in the previous 5 years and had not obtained a mammogram in the previous 2 years. Participants were block-randomized within clinic to either (i) a control arm (usual care) or (ii) a promotora-led, motivational interviewing intervention that included a home visit and telephone follow-up. At the clinic level, two of four participating clinics were provided additional mammography services delivered by a mobile mammography unit. Results: Rates of screening mammography 1 year post-randomization were 19.6% in the intervention group and 11.0% in the usual care group (P < 0.01), based on medical record data. No significant differences in participants' mammography screening were observed in clinics randomized to additional mammography services versus usual care (15.8% vs. 14.4%; P = 0.68). Conclusion: This multilevel intervention of promotora-delivered motivational interviewing and free mammography services modestly raised rates of participation in breast cancer screening among Latinas. Impact: Our findings can inform future efforts to boost mammography participation in safety net practices.
Daaleman TP, Fisher EB. Enriching patient-centered medical homes through peer support. Annals of Family Medicine. 2015;13(suppl. 1):S73-S78.
Peer supporters are recognized by various designations-community health workers, promotores de salud, lay health advisers-and are community members who work for pay or as volunteers in association with health care systems or nonprofit community organizations and often share ethnicity, language, and socioeconomic status with the mentees that they serve. Although emerging evidence demonstrates the efficacy of peer support at the community level, the adoption and implementation of this resource into patient-centered medical homes (PCMHs) is still under development. To accelerate that integration, this article addresses three major elements of peer support interventions: the functions and features of peer support, a framework and programmatic strategies for implementation, and fiscal models that would support the sustained viability of peer support programs within PCMHs.Key functions of peer support include assistance in daily management of health-related behaviors, social and emotional support, linkage to clinical care, and longitudinal or ongoing support. An organizational model of innovation implementation provides a useful framework for determining how to implement and evaluate peer support programs in PCMHs. Programmatic strategies that can be useful in developing peer support programs within PCMHs include peer coaching or mentoring, group self-management training, and programs designed around the telephone and information technology. Fiscal models for peer support programs include linkages with hospital or health care systems, service- or community-based nonprofit organizations, and partnerships between health care systems and community groups. Peer support promises to enrich PCMHs by activating patients in their self-care, providing culturally sensitive outreach, and opening the way for partnerships with community-based organizations.
Johnson SL, Gunn VL. Community health workers as a component of the health care team. Pediatr Clin North Am. 2015 Oct;62(5):1313-28.
In restructuring the delivery of primary care to improve the wellness of a community, every community must review its own circumstances for factors such as resources and capacities, health concerns, social and political perspectives, and competing priorities. Strengthening the health care team with community health workers to create a patient-centered medical home can enhance health care access and outcomes. Community health workers can serve as critical connectors between health systems and communities; they facilitate access to and improve quality and culturally sensitive medical care, emphasizing preventive and primary care.
Kenya S, Lebron C, Reyes Arrechea E, Li H. Glucometer use and glycemic control among Hispanic patients with diabetes in southern Florida. Clin Ther. 2014 Apr 1;36(4):485-93.
Background: Self-monitoring of blood glucose (SMBG) has been deemed a critical component of diabetes care in the United States. To be effective, patients must have some diabetes knowledge, glucometer proficiency, and an ability to take appropriate actions when certain readings are obtained. However, most patients take no action in response to out-of-range glucometer readings, and in many populations, SMBG practices are not associated with improved glycemic control. Thus, SMBG utilization is being reconsidered in other countries. Nonetheless, SMBG behaviors are increasingly recommended in the United States, where the Hispanic population represents the fastest-growing minority group and is disproportionately affected by suboptimal diabetes outcomes. Because a growing number of interventions aim to reduce diabetes disparities by improving glycemic control among minorities, it is essential to determine whether efforts should focus on SMBG practices. We present data on SMBG behaviors and glycemic control among participants from the Miami Healthy Heart Initiative (MHHI), a National Institutes of Health/National Heart, Lung, and Blood Institute-sponsored trial assessing a community health worker (CHW) intervention among Hispanic patients with poorly controlled diabetes. Objective: This study examined the effects of a CHW intervention on SMBG practices, glycosylated hemoglobin (HbA1c), and knowledge of appropriate responses to glucometer readings among Hispanic patients with diabetes. Methods: This study was an ancillary investigation within MHHI, a randomized, controlled trial in 300 Hispanic patients. Participants were intervention-group members who received 12 months of CHW support. Assessments were administered at baseline and poststudy to determine potential barriers to optimal health. Items from validated instruments were used to determine knowledge of appropriate responses to different glucose readings. These data were linked to HbA1c values. Means and frequencies were used to describe population characteristics and glucometer proficiency. Paired-sample t tests examined potential differences in HbA1c outcomes and SMBG practices. Qualitative data were collected from the CHWs who worked with study participants. Results:
Our population was diverse, representing several countries. Mean HbA1c improved significantly, from 10% to 8.8% (P ≤ 0.001). SMBG practices did not change. At baseline, 96% of patients reported owning a glucometer and 94% reported knowing how to use it. However, quantitative assessments and qualitative data suggested that participants had suboptimal knowledge regarding actions that could cause an out-of-range reading or how to respond to certain readings. Conclusions: SMBG behaviors were not associated with glycemic control in our sample. We conclude that a CHW intervention may improve glycemic control without improving SMBG practices. Future interventions may reconsider whether efforts should be directed toward improving SMBG behaviors.
Kyounghae K, Choi JS, Eunsuk C, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: a systematic review. Am J Public Health. 2016 Apr;106(4):e3-e28.
Background: Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities. Objectives: We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, non-communicable conditions. Search methods: We undertook 4 electronic database searches--PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane--and hand searched reference collections to identify randomized controlled trials published in English before August 2014. Selection: We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion. Data collection and analysis: Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions. Main results: All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely under-reported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 1 6.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs in to the health care delivery system was associated with cost-effective and sustainable care. Conclusions: Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.
Lechuga J, Garcia D, Owczarzak J, Barker M, Benson M. Latino community health workers and the promotion of sexual and reproductive health. Health Promot Pract. 2015 May;16(3):338-44.
Community health worker (CHW) programs have existed for over 50 years across the world. However, only recently has research evidence documented their effectiveness. Research is still needed to identify issues related to implementation and sustainability of CHW programs. This article explores the role and challenges of U.S. Latino CHWs trained to deliver a comprehensive sexual and reproductive health educational intervention to Latino families. We conducted a semistructured interview with a purposive convenience sample of 19 CHWs. Findings suggest that CHWs occupy roles that go beyond those they were trained for. CHWs serve not only as educators but also as providers of social support, facilitators of access to resources, patient navigators, and civil rights advocates. Lack of clarity of the role of a CHW influenced perceptions of adequacy of compensation, training, and integration into the agency that trained them. Policy facilitating the standardization of the CHW occupational category and role expectations is imperative to ensure successful implementation and sustainability of U.S. CHW programs.
Luque JS, Tarasenko YN, Reyes-Garcia C, et al. Salud es Vida: a Cervical Cancer Screening Intervention for Rural Latina Immigrant Women. J Cancer Educ. 2016 Jan 12. [Epub ahead of print]
This study examined the feasibility and efficacy of Salud es Vida-a promotora-led, Spanish language educational group session on cervical cancer screening (Pap tests)-self-efficacy (belief in ability to schedule and complete a Pap test), and knowledge among immigrant Hispanic/Latina women from farmworker backgrounds. These women are disproportionately burdened with cervical cancer, with mortality rates significantly higher than non-Hispanic whites. The two-arm, quasi-experimental study was conducted in four rural counties of Southeast Georgia in 2014-2015. Hispanic/Latina immigrant women aged 21-65 years and overdue for a Pap test were included as intervention (N = 38) and control (N = 52) group participants. The intervention was developed in partnership with a group of promotoras to create the toolkit of materials which includes a curriculum guide, a brochure, a flipchart, a short animated video, and in-class activities. Twelve (32 %) intervention group participants received the Pap test compared to 10 (19 %) control group participants (p = 0.178). The intervention group scored significantly higher on both cervical cancer knowledge recall and retention than the control group (p < 0.001). While there was no statistically significant difference in cervical cancer screening self-efficacy scores between the group participants, both groups scored higher at follow-up, adjusting for the baseline scores. The group intervention approach was associated with increased cervical cancer knowledge but not uptake of Pap test. More intensive interventions using patient navigation approaches or promotoras who actively follow participants or conducting one-on-one rather than group sessions may be needed to achieve improved screening outcomes with this population.
Messias DK, Parra-Medina D, Sharpe PA, et al. Promotoras de Salud: roles, responsibilities, and contributions in a multisite community-based randomized controlled trial. Hisp Health Care Int. 2013;11(2):62-71.
There is widespread recognition of the cultural and linguistic appropriateness of promotoras (a Spanish term for community health workers) in health education and outreach among Hispanic communities. Yet, there are significant gaps in the literature regarding the preparation, implementation, and evaluation of promotoras’ engagement in research. To address this gap, we examine promotoras’ research-related training, roles, responsibilities, and contributions in a community-based participatory research project involving a multisite randomized controlled trial of a physical activity intervention for Mexican-origin women in Texas and South Carolina. We identify both benefits and challenges associated with promotoras’ engagement as community researchers; examine variations and differences in roles and responsibilities related to the research contexts, sites, settings, and individual characteristics; and discuss implications for research and practice.
Molokwu J, Penaranda E, Flores S, Shokar NK. Evaluation of the effect of a promotora-led educational intervention on cervical cancer and human papillomavirus knowledge among predominantly Hispanic primary care patients on the US-Mexico Border. J Cancer Educ. 2015 Oct 27. [Epub ahead of print]
Despite declining cervical cancer rates, ethnic minorities continue to bear an unequal burden in morbidity and mortality. While access to screening is a major barrier, low levels of knowledge and cultural influences have been found to play a part in underutilization of preventive services. The aim of our study was to evaluate the effect of a promotora-led educational intervention on cervical cancer and human papillomavirus knowledge in mainly Hispanic females attending a primary care clinic. One hundred ten females were recruited from the waiting room of a busy primary care clinic and invited to attend individual or small group educational sessions. Participants completed knowledge surveys pre- and post-intervention. An overall evaluation of the educational session was also completed. Following the educational intervention, participants showed an improvement in knowledge scores from a mean score of 10.8 (SD 3.43) out of a possible score of 18 to a mean score of 16.0 (SD1.51) (p < 0.001). 94.5 % of participants rated as excellent, the presentation of information in a way that was easy to understand, most reported that it was a good use of their time and that it lowered their anxiety about testing for early detection of cervical cancer. An educational intervention delivered by well-trained Promotora/Lay health care worker significantly improves patient's cervical cancer and HPV knowledge and can be a useful tool in patient education in the clinical setting especially with high risk populations.
Moore AA, Karno MP, Ray L, et al. Development and preliminary testing of a promotora-delivered, Spanish language, counseling intervention for heavy drinking among male, Latino day laborers. J Subst Abuse Treat. 2016 Mar;62:96-101.
This study developed and then tested the feasibility, acceptability and initial efficacy of a 3-session, culturally adapted, intervention combining motivational enhancement therapy (MET) and strengths-based case management (SBCM) delivered by promotoras in Spanish to reduce heavy drinking among male, Latino day laborers. A pilot two-group randomized trial (N=29) was conducted to evaluate the initial efficacy of MET/SBCM compared to brief feedback (BF). Alcohol-related measures were assessed at 6, 12 and 18 weeks after baseline. Most intervention group participants (12/14) attended all counseling sessions and most participants (25/29) remained in the study at 18 weeks. Alcohol related measures improved in both groups over time with no statistically significant differences observed at any of the time points. However the comparative effect size of MET/SBCM on weekly drinking was in the large range at 6-weeks and in the moderate range at 12-weeks. Post hoc analyses identified a statistically significant reduction in number of drinks over time for participants in the intervention group but not for control group participants. Despite the extreme vulnerability of the population, most participants completed all sessions of MET/SBCM and reported high satisfaction with the intervention. We feel our community partnership facilitated these successes. Additional studies of community-partnered and culturally adapted interventions are needed to reduce heavy drinking among the growing population of Latinos in the U.S.
Morgan K, Lee J, Sebar B. Community health workers: a bridge to healthcare for people who inject drugs. Int J Drug Policy. 2015 Apr;26(4):380-7.
Background: Although people who inject drugs (PWIDs) have increased healthcare needs, their poor access and utilisation of mainstream primary healthcare services is well documented. To address this situation, community health workers (CHWs) who have personal experience of drug injecting in addition to healthcare training or qualifications are sometimes utilised. However, the role peer workers play as members of clinical primary healthcare teams in Australia and how they manage the healthcare needs of PWID, has been poorly documented. Methods: A qualitative ethnomethodological approach was used to study the methods used by CHWs. Data was collected using participant observation of CHWs in a PWID-targeted primary healthcare centre. CHW healthcare consultations with PWID were audio-recorded and transcribed verbatim. Transcripts along with field notes were analysed using membership categorisation and conversation analysis techniques to reveal how CHWs' personal and professional experience shapes their healthcare interactions with PWID clients. Results: CHWs' personal experience of injecting drug use is an asset they utilise along with their knowledge of clinical practice and service systems. It provides them with specialised knowledge and language--resources that they draw upon to build trust with clients and accomplish transparent, non-judgmental interactions that enable PWID clients to be active participants in the management of their healthcare. Existing literature often discusses these principles at a theoretical level. This study demonstrates how CHWs achieve them at a micro-level through the use of indexical language and displays of the membership categories 'PWID' and 'healthcare worker'. Conclusion: This research explicates how CHWs serve as an interface between PWID clients and conventional healthcare providers. CHWs deployment of IDU-specific language, membership knowledge, values and behaviours, enable them to interact in ways that foster transparent communication and client participation in healthcare consultations. The incorporation of community health workers into clinical healthcare teams working with IDU populations is a possible means for overcoming barriers to healthcare, such as mistrust and fear of stigma and discrimination, because CHWs are able to serve as an interface between PWID and other healthcare providers.
Najafizada SA, Bourgeault IL, Labonte R, Packer C, Torres S. Community health workers in Canada and other high-income countries: A scoping review and research gaps. Can J Public Health. 2015 Mar 12;106(3):e157-64.
Objectives: Community health workers (CHWs) have been deployed to provide health-related services to their fellow community members and to guide them through often complex health systems. They help address concerns about how marginalized populations in many countries experience health inequities that are due, in part, to lack of appropriate primary health care services, possibly resulting in inappropriate use of higher-cost health services or facilities. This paper reviews studies on CHW interventions in a number of high-income countries, including Canada, to identify research gaps on CHW roles. Methods: A scoping review using 68 sources of interventions involving CHWs was undertaken. The five-step Arksey and O'Malley model guided this review with the aim of summarizing research findings and identifying research gaps in the existing literature on CHWs in Canada (23 sources). A standardized extraction tool was employed to synthesize the literature. Synthesis: We found that CHWs provide a wide range of health-related services but in a manner that, in Canada, is unrecognized and unregulated. In high income countries, CHW interventions have contributed to health-related issues in communities and demonstrated potential to both reduce health inequity in marginalized populations and reduce the cost of medical services. Conclusion: CHWs are an under-recognized, and therefore underutilized, public health workforce, which has a promising capacity to reduce health inequities in marginalized populations in Canada. There is growing support to suggest that CHW roles need to be better integrated within the broader health and social services systems to enable their full potential to be realized.
Nguyen BH, Stewart SL, Nguyen TT, et al. Effectiveness of lay health worker outreach in reducing disparities in colorectal cancer screening in Vietnamese Americans. Am J Public Health. 2015 Oct;105(10):2083-9.
Objectives: We conducted a cluster randomized controlled study of a lay health worker (LHW) intervention to increase colorectal cancer (CRC) screening rates among Vietnamese Americans, who typically have lower rates than do non-Hispanic Whites. Methods: We randomized 64 LHWs to 2 arms. Each LHW recruited 10 male or female participants who had never had CRC screening (fecal occult blood test, sigmoidoscopy, or colonoscopy). Intervention LHWs led 2 educational sessions on CRC screening. Control LHWs led 2 sessions on healthy eating and physical activity. The main outcome was self-reported receipt of any CRC screening at 6 months after the intervention. We conducted the study from 2008 to 2013 in Santa Clara County, California. Results: A greater proportion of intervention participants (56%) than control participants (19%) reported receiving CRC screening (P < .001). When controlling for demographic characteristics, the intervention odds ratio was 5.45 (95% confidence interval = 3.02, 9.82). There was no difference in intervention effect by participant gender. Conclusions: LHW outreach was effective in increasing CRC screening in Vietnamese Americans. Randomized controlled trials are needed to test the effectiveness of LHW outreach for other populations and other health outcomes.
Palmas W, March D, Darakjy S, Findley SE, et al. Community health worker interventions to improve glycemic control in people with diabetes: a systematic review and meta-analysis. J Gen Intern Med. 2015 Jul;30(7):1004-12.
Objectives: We set out to review the efficacy of Community Health Worker (CHW) interventions to improve glycemia in people with diabetes. Methods: Data sources included the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, Google Scholar, and reference lists of previous publications. We reviewed randomized controlled trials (RCTs) that assessed the efficacy of CHW interventions, as compared to usual care, to lower hemoglobin A1c (A1c). Two investigators independently reviewed the RCTs and assessed their quality. Only RCTs with a follow-up of at least 12 months were meta-analyzed. A random effects model was used to estimate, from unadjusted within-group mean reductions, the standardized mean difference (SMD) in A1c achieved by the CHW intervention, beyond usual care. Results: Thirteen RCTs were included in the narrative review, and nine of them, which had at least 12 months of follow-up, were included in the meta-analysis. Publication bias could not be ruled-out due to the small number of trials. Outcome heterogeneity was moderate (I(2)= 37%). The SMD in A1c (95% confidence interval) was 0.21 (0.11-0.32). Meta-regression showed an association between higher baseline A1c and a larger effect size. Conclusions: CHW interventions showed a modest reduction in A1c compared to usual care. A1c reduction was larger in studies with higher mean baseline A1c. Caution is warranted, given the small number of studies.
Parra-Medina D1, Morales-Campos DY, Mojica C, Ramirez AG. Promotora outreach, education and navigation support for HPV vaccination to Hispanic women with unvaccinated daughters. J Cancer Educ. 2015 Jun;30(2):353-9.
Cervical cancer disparities persist in the predominantly Hispanic population of South Texas, and Hispanic girls are less likely to initiate and complete the three-dose human papillomavirus (HPV) vaccine series. Culturally relevant interventions are needed to eliminate these disparities and improve HPV vaccine initiation and completion. We enrolled 372 Hispanic women from South Texas' Cameron and Hidalgo counties with a daughter, aged 11-17, who had not received HPV vaccine. All participants received an HPV vaccine educational brochure in their preferred language (English or Spanish) and were invited to participate in the Entre Madre e Hija (EMH) program, a culturally relevant cervical cancer prevention program. EMH participants (n = 257) received group health education, referral and navigation support from a promotora (a trained, culturally competent community health worker). Those who declined participation in EMH received the brochure only (n = 115). Eighty-four percent of enrolled participants initiated the HPV vaccine, and no differences were observed between EMH program and brochure-only participants. Compared to brochure-only participants, EMH participants were more likely to complete the vaccine series [adjusted odds ratio (adj. OR) = 2.24, 95% CI (1.25, 4.02)]. In addition, participants who were employed and insured had lower odds of completing the vaccine series [adj. OR = 0.45, 95% CI (0.21-0.96); adj. OR = 0.36, 95% CI (0.13-0.98), respectively]. All enrolled participants had high vaccine initiation rates (>80%); however, EMH program participants were more likely to complete the vaccine series. HPV vaccine promotion efforts that include referral and navigation support in addition to education show promise.
Ramirez DM, Ramírez-Andreotta MD, Vea L, et al. Pollution prevention through peer education: a community health worker and small and home-based business initiative on the Arizona-Sonora border. Int J Environ Res Public Health. 2015 Sep 9;12(9):11209-26.
Government-led pollution prevention programs tend to focus on large businesses due to their potential to pollute larger quantities, therefore leaving a gap in programs targeting small and home-based businesses. In light of this gap, we set out to determine if a voluntary, peer education approach led by female, Hispanic community health workers (promotoras) can influence small and home-based businesses to implement pollution prevention strategies on-site. This paper describes a partnership between promotoras from a non-profit organization and researchers from a university working together to reach these businesses in a predominately Hispanic area of Tucson, Arizona. From 2008 to 2011, the promotora-led pollution prevention program reached a total of 640 small and home-based businesses. Program activities include technical trainings for promotoras and businesses, generation of culturally and language appropriate educational materials, and face-to-face peer education via multiple on-site visits. To determine the overall effectiveness of the program, surveys were used to measure best practices implemented on-site, perceptions towards pollution prevention, and overall satisfaction with the industry-specific trainings. This paper demonstrates that promotoras can promote the implementation of pollution prevention best practices by Hispanic small and home-based businesses considered "hard-to-reach" by government-led programs.
Rashid S, Carcel C, Morphew T, Amaro S, Galant S. Effectiveness of a promotora home visitation program for underserved Hispanic children with asthma. J Asthma. 2015 Jun;52(5):478-84.
Objective: Retention in a mobile asthma clinic, the Breathmobile™, of ≥3 visits has previously been shown to be essential for attaining asthma control in underserved children. The objective of this study in primarily Hispanic-American children was to determine the difference in retention between those seen in the Breathmobile™ compared to those receiving an additional promotora-based home visit (HV). Methods: Children with asthma in the Breathmobile™ program were evaluated for asthma status and aeroallergen sensitivity. Indication for HV included poor asthma control, educational and environmental control needs. An initial visit consisted of environmental assessment as well as a 3-h interactive educational session covering asthma basics. A follow-up visit 1 month later assessed implementation. The primary outcome measure of retention was ≥6 months in the Breathmobile™ program. Results: Of the 1007 asthmatic children seen between April 2002 and June of 2005, 136 received HV. These children showed significantly greater retention compared to those without HV with a median number of visits (5 visits versus 2 visits), ≥3 Breathmobile™ visits (86.0% versus 38.8%), median number of days in the program (299 versus 63 days) and percentage of patients in the program ≥6 months (67.8% versus 31.3%) p < 0.001. HV and asthma severity were each independent predictors of retention. Conclusions: The addition of a promotora HV program proved effective in providing greater retention in the Breathmobile™ program essential for asthma control. Randomized clinical trials will be needed to show the impact on health care utilization and asthma control.
Redding S, Conrey E, Porter K, Paulson J, Hughes K, Redding M. Pathways community care coordination in low birth weight prevention. Matern Child Health J. 2015 Mar;19(3):643-50.
The evidence is limited on the effectiveness of home visiting care coordination in addressing poor birth outcome, including low birth weight (LBW). The Community Health Access Project (CHAP) utilizes community health workers (CHWs) to identify women at risk of having poor birth outcomes, connect them to health and social services, and track each identified health or social issue to a measurable completion. CHWs are trained individuals from the same highest risk communities. The CHAP Pathways Model is used to track each maternal health and social service need to resolution and CHWs are paid based upon outcomes. We evaluated the impact of the CHAP Pathways program on LBW in an urban Ohio community. Women participating in CHAP and having a live birth in 2001 through 2004 constituted the intervention group. Using birth certificate records, each CHAP birth was matched through propensity score to a control birth from the same census tract and year. Logistic regression was used to examine the association of CHAP participation with LBW while controlling for risk factors for LBW. We identified 115 CHAP clients and 115 control births. Among the intervention group there were seven LBW births (6.1 %) compared with 15 (13.0 %) among non-CHAP clients. The adjusted odds ratio for LBW was 0.35 (95 % confidence interval, 0.12-0.96) among CHAP clients. This study provides evidence that structured community care coordination coupled with tracking and payment for outcomes may reduce LBW birth among high-risk women.
Richardson BS, Willig AL, Agne AA, Cherrington AL. Diabetes connect: African American women's perceptions of the community health worker model for diabetes care. J Community Health. 2015 Oct;40(5):905-11.
Community health worker (CHW) interventions have potential to improve diabetes outcomes and reduce health disparities. However, few studies have explored patient perspectives of peer-delivered diabetes programs. The purpose of this qualitative study is to investigate possible benefits as well as risks of CHW-delivered peer support for diabetes from the perspectives of African American women living with type 2 diabetes in Jefferson County, Alabama. Four ninety-minute focus groups were conducted by a trained moderator with a written guide to facilitate discussion on the topic of CHWs and diabetes management. Participants were recruited from the diabetes education database at a safety-net hospital. Two independent reviewers performed content analysis to identify major themes using a combined deductive-inductive approach. There were 25 participants. Mean years with diabetes was 11.2 (range 6 months to 42 years). Participants were knowledgeable about methods for self-management but reported limited resources and stress as major barriers. Preferred CHW roles included liaison to the healthcare system and easily accessible information source. Participants preferred that the CHW be knowledgeable and have personal experience managing their own diabetes or assisting a family member with diabetes. Concerns regarding the CHW-model were possible breaches of confidentiality and privacy. The self-management strategies and barriers to management identified by participants were reflected in their preferred CHW roles and traits. These results suggest that African American women with diabetes in Alabama would support peer-led diabetes education that is community-based and socially and emotionally supportive.
Rios-Ellis B, Nguyen-Rodriguez ST, Espinoza L, et al. Engaging community with promotores de salud to support infant nutrition and breastfeeding among Latinas residing in Los Angeles County: Salud con Hyland's. Health Care Women Int. 2015;36(6):711-29.
The Salud con Hyland's Project: Comienzo Saludable, Familia Sana [Health With Hyland's Project: Healthy Start, Healthy Family],was developed to provide education and support to Latina mothers regarding healthy infant feeding practices and maternal health. The promotora-delivered intervention was comprised of two charlas (educational sessions) and a supplemental, culturally and linguistically relevant infant feeding and care rolling calendar. Results indicate that the intervention increased intention to breastfeed exclusively, as well as to delay infant initiation of solids by 5 to 6 months. Qualitative feedback identified barriers to maternal and child health education as well as highlighted several benefits of the intervention.
Rios-Ellis B, Becker D, Espinoza L, et al. Evaluation of a community health worker intervention to reduce HIV/AIDS stigma and increase HIV testing among underserved Latinos in the southwestern U.S. Public Health Rep. 2015 Sep-Oct;130(5):458-67.
Objectives: Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos. Methods: An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200). Results: From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one's sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively). Conclusion: Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.
Rojas E, Gerber BS, Tilton J, Rapacki L, Sharp LK. Pharmacists' perspectives on collaborating with community health workers in diabetes care. J Am Pharm Assoc. 2015 Jul-Aug;55(4):429-33.
Objectives: To qualitatively assess pharmacists' perspectives on the barriers and facilitators of collaborating with community health workers (CHWs) when caring for patients with diabetes. Methods:
Eight pharmacists were invited to participate in a focus group. All pharmacists had worked with CHWs for 12 months as part of a larger study. Seven pharmacists participated in a single focus group while one pharmacist participated in an individual interview. Data were analyzed by two investigators to identify common themes. Results: Perceived barriers included issues associated with maintaining patient confidentiality, pharmacists' level of comfort with CHWs, uncertainty about CHW roles, and inconsistent communication between pharmacists and CHWs. However, pharmacists reported that the care model fostered improvement in patient-pharmacist communication, patient adherence to medication, and assessment of patients' overall condition. Conclusion: Pharmacists expressed positive attitudes and experiences in working with CHWs caring for a minority patient population with poorly controlled diabetes. Most believed that CHWs acted as facilitators and aided them in producing positive clinical outcomes by addressing the multiple psychosocial and contextual dimensions of patient health. Developing approaches for more frequent and effective communication between pharmacists and CHWs was the primary perceived challenge.
Shahidi H, Sickora C, Clancy S, Nagurka R. Community health workers recruitment from within: an inner-city neighborhood-driven framework. BMC Res Notes. 2015 Nov 24;8:715. doi: 10.1186/s13104-015-1700-0.
Background: Community health workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served (APHA 2009). Among other roles, they are effective in closing critical communication gap between healthcare providers and patients as they possess key abilities to overcome cultural barriers, minimize disparities, and maximize adherence to clinical directions. In previous descriptions of the selection of CHWs, the role of community is clearly emphasized, but residence in the community is not indicated. Objective: We present an effective model of CHW selection by the community of members that reside in the community to be served. Methods: We outlined and implemented necessary steps for recruiting CHWs from within their target neighborhood between years 2011 and 2013. The identified community was an "isolated" part of Newark, New Jersey comprised of approximately 3000 people residing in three publicly-funded housing developments. We utilized a community empowerment model and established a structure of self-governance in the community of interest. In all phases of identification and selection of CHWs, the Community Advisory Board (CAB) played a leading role. Results: The process for the successful development of a CHW initiative in an urban setting begins with community/resident engagement and ends with employment of trained CHWs. The steps needed are: (1) community site identification; (2) resident engagement; (3) health needs assessment; (4) CHW identification and recruitment; and (5) training and employment of CHWs. Using an empowered community model, we successfully initiated CHW selection, training, and recruitment. Thirteen CHW candidates were selected and approved by the community. They entered a 10-week training program and ten CHWs completed the training. We employed these ten CHWs. Conclusions: These five steps emerged from a retrospective review of our CHW initiative. Residing in the community served has significant advantages and disadvantages. Community empowerment is critical in changing the health indices of marginalized communities.
Siemon M, Shuster G, Boursaw B. The impact of state certification of community health workers on team climate among registered nurses in the United States. J Community Health. 2015 Apr;40(2):215-21.
A number of states have adopted certification programs for community health workers (CHWs) to improve recognition of CHWs as members of health care teams, increase oversight, and to provide sustainable funding. There has been little research into the impact of state CHW certification on the diffusion and adoption of CHWs into existing health care systems. This study examined the impact of state CHW certification on the perceptions of team climate among registered nurses (RNs) who work with CHWs in states with and without CHW certification programs. The study recruited RNs using a purposeful sampling method and used an online survey, which included the Team Climate Inventory (TCI), and compared the perceptions of team climate between the two groups. The study found no significant differences in the overall mean TCI score or TCI subscale scores between RNs who work in states with CHW certification programs (n = 81) and those who work in states without CHW certification programs (n = 115). There was a statistically significant difference on one survey question regarding whether RNs believe state certification of CHWs improved the ability of their health care team to deliver quality care. More research is needed to assess impact of state certification of CHWs and other factors that influence the diffusion and adoption of CHWs into the current health care system.
Verhagen I, Steunenberg B, de Wit NJ, Ros WJ. Community health worker interventions to improve access to health care services for older adults from ethnic minorities: a systematic review. BMC Health Serv Res. 2014 Nov 13;14:497. doi: 10.1186/s12913-014-0497-1.
Background: The health status of older adults belonging to ethnic minorities in Western countries is an important public issue because their health is often less favourable than that of older adults from the majority population. In addition, the number of older adults belonging to ethnic minorities is increasing rapidly in Western countries. The introduction of community health workers (CHWs) has proven to be successful in addressing health disparities among ethnic minorities; however, an overview of CHW's benefits for older adults is absent in the literature. We reviewed the literature to explore whether CHWs are also effective in improving the health and the delivery of health care services to ethnic minority older adults in Western countries. Methods: We searched the PubMed database (2002-Present) for RCTs published on the use of CHWs in Western countries. Results: Out of the 729 studies identified, seven studies met our inclusion criteria. The effectiveness of the implementation of CHW programmes in older adults belonging to ethnic minorities is not univocal. In two studies, we found no significant differences. In five studies, we found some positive effects. We did not find negative effects in any of the studies. For better interpretation of the results, effect ratios (ERs) were calculated as the number of positive findings divided by the total number of measured findings. Substantial effects on the access to care (mean ER = 0.58) and on health behaviour (mean ER = 0.45) were found. The mean ER for health outcomes was considerably lower (mean ER = 0.17). Conclusion: We found indications that CHWs serve as a means of improving health care use and health behaviour and, to a lesser extent, health outcomes among ethnic minority older adults. Further research is required to draw more solid conclusions on the effectiveness of CHW interventions in this target group. This is particularly important for Western countries in which the number of ethnic minority older adults has increased significantly because their health status is mostly unfavourable and their access to health care services is often limited.
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