Community Health Worker / Promotor(a) Resources

For further information on promotoras/es and community health workers training and certification program in Texas, go to the Texas Department of State Health Services Community Health Worker or Promotor(a) Training and Certification Program webpage.

The Medical and Research Librarians have selected this list of journal articles and/or reports in the Promotor(a) or Community Health Worker Training and Certification Program. 

Anugu M, Braksmajer A, Huang J, et al. Enriched medical home intervention using community health worker home visitation and ED use. Pediatrics. 2017 May;139(5). pii: e20161849. doi: 10.1542/peds.2016-1849. 
Background and Objectives: Community health workers (CHWs) have great potential to extend medical home services and reduce emergent health care use, but evidence in pediatrics is scarce. We evaluated the impact of an existing enriched medical home intervention (EMHI) that directly integrates CHWs into the emergency department (ED) visits and hospitalizations for pediatric ambulatory care-sensitive conditions (ACSCs). Methods: The EMHI group in this prospective cohort study received home visits from trained CHWs to support adherence to recommended care; the comparison group received usual care (UC). Sociodemographic characteristics were compiled from the EMHI database, and ED and hospitalization information was extracted for study participants from a statewide database. The Wilcoxon signed-rank test was used to compare ED data and the Wald test was used to compare hospitalization use for ACSCs between the intervention and UC groups after adjusting for different characteristics between groups by using the propensity score matching method. Results: The study sample included 922 children (225 intervention, 697 UC). After propensity score matching, the analytic sample included 450 children (225 intervention, 225 UC). After propensity score matching, the intervention group was significantly less likely than the UC group to visit the ED for an ACSC (18.2% vs 35.1%; P = .004). We found no differences in ACSC hospitalizations between the 2 groups. Conclusions: Our findings suggest that EMHIs using trained CHWs may be a cost-effective model to reduce preventable ED utilization, especially among vulnerable children.

Aponte J, Jackson TD, Wyka K, Ikechi C. Health effectiveness of community health workers as a diabetes self-management intervention. Diab Vasc Dis Res. 2017 Jul;14(4):316-326. doi: 10.1177/1479164117696229.
Objective: To evaluate the health effectiveness of community health workers among three groups (intervention, attentional control, and control groups) of Hispanic adults with uncontrolled (HbA1c >8%) type 2 diabetes mellitus. Methods: This was a randomized clinical trial involving 180 English- and Spanish-speaking Hispanic individuals with uncontrolled type 2 diabetes mellitus, 40-74 years of age, who received diabetes care at an outpatient, public, urban hospital. Repeated-measures analysis of variance was used to evaluate the effect of time and group on the primary outcome measure and secondary outcomes. Group differences in the percentage of participants achieving at least a 1% reduction in HbA1c levels were assessed using chi-square tests. Results: Patients' ages ranged from 44 to 74 years, 40% were male, 97% preferred Spanish and seven Spanish-speaking countries were identified as a country of origin. Relative to the control and attentional control groups, the intervention group showed greater HbA1c reduction from baseline to 12 months and was the group with the highest percentage of participants showing 1% or more HbA1c reduction. Conclusion: Integration of community health workers improved disease control for patients with type 2 diabetes mellitus during the intervention phase. Peer-driven/interactive ways to sustain diabetes control need to be explored.

Basu S, Jack HE, Arabadjis SD, Phillips RS. Benchmarks for reducing emergency department visits and hospitalizations through community health workers integrated into primary care: a cost-benefit analysis. Med Care. 2017 Feb;55(2):140-147.
Background: Uncertainty about the financial costs and benefits of community health worker (CHW) programs remains a barrier to their adoption. Objectives: To determine how much CHWs would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective. Research Design: Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources. Results: CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality, 4-5 visits to the ED would need to be averted per year by a CHW assigned to a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost savings. Conclusion: Offsetting the costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

Carrasquillo O, Lebron C, Alonzo Y, et al. Effect of a community health worker intervention among Latinos with poorly controlled type 2 diabetes: the Miami healthy heart initiative randomized clinical trial. JAMA Intern Med. 2017 Jul 1;177(7):948-954.
Importance: Community health worker (CHW) intervention is a promising approach to addressing type 2 diabetes among Latinos. However, evidence from randomized clinical studies is limited. Objective: To compare a CHW intervention with enhanced usual care. Design, Setting, and Participants: This 52-week, the single-blind, randomized clinical trial included 300 Latino adults aged 18 to 65 years who were treated in 2 public hospital outpatient clinics in Miami-Dade County, Florida, from July 1, 2010, through October 31, 2013. Eligible participants had a hemoglobin A1c (HbA1c) level of 8.0 or greater. Follow-up was completed on January 31, 2015, and data were analyzed from March 10, 2015, to June 6, 2016. Interventions: A 1-year CHW intervention consisted of home visits, telephone calls, and group-level activities. Main Outcomes and Measures: Primary outcomes included systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDLC) levels, and HbA1c levels. Secondary outcomes included body mass index, medication regimen intensification, and self-reported measures of diet, physical activity, and medication regimen adherence. Results: Of the 300 participants randomized (135 men [45%] and 165 women [55%]; mean [SD] age, 55.2 [7.0] years), we obtained follow-up data on 215 (71.7%). Participants in the CHW group received a median of 4 home visits and 20 telephone calls. After adjusting for baseline values and covariates, participants in the CHW group had an HbA1c level that was 0.51% lower (95% CI, -0.94% to -0.08%) than that of participants in the enhanced usual care group. The reduction in SBP of 4.62 mm Hg (95% CI, -9.01 to -0.24 mm Hg) did not meet the preplanned target of 8 mm Hg and was not statistically significant in unadjusted models. No significant differences in LDLC levels (mean difference, -8.2 mg/dL; 95% CI, -18.8 to 2.3 mg/dL) or any of the preplanned secondary outcomes were observed. Post hoc analyses suggest that the intervention may be more beneficial among those with worse control of their type 2 diabetes at baseline. Conclusions and Relevance: Among Latinos with poorly controlled type 2 diabetes, a 12-month CHW intervention lowered HbA1c levels by 0.51%. The intervention did not lead to improvements in LDLC levels, and the findings with respect to SBP were variable and half of what was targeted. Future studies should examine whether CHW interventions affect other measures, such as access to health care or social determinants of health.

D'Alonzo KT, Smith BA, Dicker LH. Outcomes of a culturally tailored partially randomized patient preference controlled trial to increase physical activity among low-income immigrant Latinas. J Transcult Nurs. 2017 Jul 1:1043659617723073. doi: 10.1177/1043659617723073. [Epub ahead of print]
Introduction: Almost half (47.8%) of adult Latinas report they never engage in any leisure-time physical activity (PA) which is an independent risk factor for the development of cardiovascular disease and other chronic illnesses. There is a pressing need to develop and test PA interventions among Latinas. Therefore, the purpose of this study was to evaluate the effects of a PA Intervention for Latinas, a culturally tailored, promotora-facilitated 12-week PA intervention. It was hypothesized that at the completion of the intervention, participants would have (a) higher daily PA levels; (b) improved aerobic fitness, muscle strength, and flexibility; and (c) lower body mass index and percentage of body fat. Methodology: A partially randomized patient preference trial design with a lag group was used to test the intervention. Participants (N = 76) attended twice weekly; low-impact aerobics/Latin dance PA classes taught by laywomen trained as promotoras. Results: Significant improvements were measured in aerobic fitness, muscle strength and flexibility, and daily PA levels (p < .001). Sixty percent of the participants attended at least 60% of the PA sessions. Discussion: Findings suggest laywomen trained as promotoras can successfully facilitate the delivery of an intervention to increase PA among immigrant Latinas.

Daniels AS, Bergeson S, Myrick KJ. Defining peer roles and status among community health workers and peer support specialists in integrated systems of care. Psychiatr Serv. 2017 Jul 17:appips201600378. doi: 10.1176/appi.ps.201600378. [Epub ahead of print]
Current strategies for integrating general medical and behavioral health services focus primarily on improving the coordination of care and expanding team-based services. Absent from most discussion has been a focus on the workforces that provide the bulk of community-based outreach, engagement, activation, motivational support, and self-management: community health workers (CHWs) and peer support specialists (PSSs). CHWs have primarily been deployed in general medical care and PSSs in behavioral health care. Understanding the unique contributions that CHWs and PSS provide for health promotion and wellness and improved population health outcomes is an important challenge. This Open Forum reviews the key elements of peer status as a way to help illustrate the differences between these workforces and the best deployment strategies for each workforce. A framework is proposed that outlines key support roles provided by the CHW and PSS workforces.

DeAngelis KR, Dore KF, Dean D, Osterman P. Strengthening the healthy start workforce: a mixed-methods study to understand the roles of community health workers in healthy start and inform the development of a standardized training program. Matern Child Health J. 2017 Nov 18. doi: 10.1007/s10995-017-2377-x.
Introduction Healthy Start (HS) is dedicated to preventing infant mortality, improving birth outcomes, and reducing disparities in maternal and infant health. In 2014, the HS program was reenvisioned and standardization of services and workforce development were prioritized. This study examined how HS community health workers (CHW), as critical members of the workforce, serve families and communities in order to inform the development of a CHW training program to advance program goals. Methods In 2015, an online organizational survey of all 100 HS programs was conducted. Ninety-three sites (93%) responded. Three discussion groups were subsequently conducted with HS CHWs (n = 21) and two discussion groups with HS CHW trainers/supervisors (n = 14). Results Most (91%) respondent HS programs employed CHWs. Survey respondents ranked health education (90%), assessing participant needs (85%), outreach/recruitment (85%), and connecting participants to services (85%) as the most central roles to the CHW's job. Survey findings indicated a large variation in CHW training, both in the amount and content provided. Discussion group findings provided further examples of the knowledge and skills required by HS CHWs. Conclusions The study results, combined with a scan of existing competencies, led to a tailored set of competencies that serve as the foundation for an HS CHW training program. This training program has the capacity to advance strategic goals for HS by strengthening HS CHWs' capacity nationwide to respond to complex participant needs. Other maternal and child health programs may find these results of interest as they consider how CHWs could be used to strengthen service delivery.

Falbe J, Friedman LE, Sokal-Gutierrez K, et al. "She gave me the confidence to open up": bridging communication by promotoras in a childhood obesity intervention for Latino families. Health Educ Behav. 2017 Aug 1:1090198117727323. doi: 10.1177/1090198117727323. [Epub ahead of print]
Childhood obesity is a public health threat that disproportionally affects Latino youth in the United States. Active and Healthy Families (AHF) is a culturally tailored, family-based program for addressing obesity disparities in a predominantly immigrant Latino population. AHF was the first primary care, culturally tailored intervention for Latino children to significantly reduce BMI in a randomized controlled trial. The 10-week AHF intervention reduced BMI (kg/m2) among overweight or obese children by 0.5, compared with an increase of 0.3 in the control group, yielding a -0.8 difference ( p < .01). A unique aspect of the program is its provider team: a physician, dietitian, and promotora. Because early feedback from families highlighted the importance of promotoras specifically, we sought to understand the unique mechanisms of promotora effectiveness in AHF. We conducted in-depth, semistructured interviews with the AHF providers ( n = 5) and parent participants ( n = 23) by phone between November 2012 and May 2013. In a grounded theory analysis, three main categories encompassing five themes emerged: (a) bridging communication by promotoras; (b) promotoras' personal qualities, including themes of kindness and caring and shared experiences with patients; and (c) impactful task performance, including themes of motivation, positive environment, and self-efficacy. Together, the themes serve as the basis of a conceptual model illustrating the process through which promotoras may enhance the impact of team-based obesity programs for the Latino community. Because this study identifies the specific ways through which promotoras can bridge cultural, linguistic, and other divides, it may inform the development and dissemination of evidence-based approaches for obesity prevention in the Latino community.

Finlayson TL, Asgari P, Hoffman L, et al. Formative research: using a community-based participatory research approach to develop an oral health intervention for migrant Mexican families. Health Promot Pract. 2017 May;18(3):454-465.
Oral health is a leading unmet health need among migrant families. This article describes the 1-year, community-based participatory research (CBPR) approach employed to plan and develop a Líder Comunitario (lay community health worker)-led educational intervention for Mexican migrant adult caregivers and their families in three underserved, remote communities in North San Diego County, California. Four partner organizations collaborated, reviewed existing oral health curricula, and sought extensive input on educational topics and research design from key informants, migrant caregivers, and Líderes Communitarios. Based on community stakeholder input, partners developed a logic model and drafted educational intervention materials. Key informants (n = 28), including several members from two community advisory boards, ranked program priorities and intervention subgroup populations via an online survey. Three focus groups were conducted with Líderes Comunitarios (n = 22) and three with migrant families (n = 30) regarding the oral health program's design and content. Twelve Líderes Comunitarios reviewed draft intervention materials during two focus groups to finalize the curriculum, and their recommended changes were incorporated. Formative research results indicated that community stakeholders preferred to focus on adult caregivers and their families. A 5-week educational intervention with hands-on demonstrations and colorful visuals was developed, covering the following topics: bacteria and tooth decay, oral hygiene, nutrition, gum disease, and dental services. The CBPR process engaged multiple community stakeholders in all aspects of planning and developing the educational intervention.

Flores AL, Isenburg J, Hillard CL, et al. Folic acid education for Hispanic women: the Promotora de Salud model. J Womens Health (Larchmt). 2017 Jan 9. doi: 10.1089/jwh.2016.6116. [Epub ahead of print]
Background: Although rates of neural tube defects (NTDs) have declined in the United States since fortification, disparities still exist with Hispanic women having the highest risk of giving birth to a baby with a NTD. The Promotora de Salud model using community lay health workers has been shown to be an effective tool for reaching Hispanics for a variety of health topics; however, literature on its effectiveness in folic acid interventions is limited. Materials and Methods: An intervention using the Promotora de Salud model was implemented in four U.S. counties with large populations of Hispanic women. The study comprised the following: (1) a written pretest survey to establish baseline levels of folic acid awareness, knowledge, and consumption; (2) a small group education intervention along with a 90-day supply of multivitamins; and (3) a postintervention (posttest) assessment conducted 4 months following the intervention. Results: Statistically significant differences in pre-and post-tests were observed for general awareness about folic acid and vitamins and specific knowledge about the benefits of folic acid. Statistically significant changes were also seen in vitamin consumption and multivitamin consumption. Folic acid supplement consumption increased dramatically by the end of the study. Conclusions: The Promotora de Salud model relies on interpersonal connections forged between promotoras and the communities they serve to help drive positive health behaviors. The findings underscore the positive impact that these interpersonal connections can have on increasing awareness, knowledge, and consumption of folic acid. Utilizing the Promotora de Salud model to reach targeted populations might help organizations successfully implement their programs in a culturally appropriate manner.

Galbraith AA, Meyers DJ, Ross-Degnan D, et al. Long-term impact of a postdischarge community health worker intervention on health care costs in a safety-net system. Health Serv Res. 2017 Dec;52(6):2061-2078. doi: 10.1111/1475-6773.12790.
Objective: Patient navigators (PNs) may represent a cost-effective strategy to improve transitional care and reduce hospital readmissions. We evaluated the impact of a PN intervention on health system costs in the 180 days after discharge for high-risk patients in a safety-net system. Data Source/Setting: Primary and secondary data from an academic safety-net health system. Study Design: We compared per-patient utilization and costs, overall and by age, for high-risk, medical service patients randomized to the PN intervention relative to usual care between October 2011 and April 2013. Intervention patients received hospital visits and telephone outreach from PNs for 30 days after every qualifying discharge. Data Collection/Extraction Methods: We used administrative and electronic encounter data, and a survey of nurses; costs were imputed from the Medicare fee schedule. Principal Findings: Total costs per patient over the 180 days post-index discharge for those aged ≥60 years were significantly lower for PN patients compared to controls ($5,676 vs. $7,640, p = .03); differences for patients aged <60 ($9,942 vs. $9,046, p = .58) or for the entire cohort ($7,092 vs. $7,953, p = .27) were not significant. CONCLUSIONS: Patient navigator interventions may be useful strategies for specific groups of patients in safety-net systems to improve transitional care while containing costs.

Green NS, Manwani D, Matos S, et al. Randomized feasibility trial to improve hydroxyurea adherence in youth ages 10-18 years through community health workers: The HABIT study. Pediatr Blood Cancer. 2017 Dec;64(12). doi: 10.1002/pbc.26689.
Introduction: The main therapeutic intervention for sickle cell disease (SCD) is hydroxyurea (HU). The effect of HU is largely through dose-dependent induction of fetal hemoglobin (HbF). Poor HU adherence is common among adolescents. Methods: Our 6-month, two-site pilot intervention trial, "HABIT," was led by culturally aligned community health workers (CHWs). CHWs performed support primarily through home visits, augmented by tailored text message reminders. Dyads of youth with SCD ages 10-18 years and a parent were enrolled. A customized HbF biomarker, the percentage decrease from each patient's highest historical HU-induced HbF, "Personal best," was used to qualify for enrollment and assess HU adherence. Two primary outcomes were as follows: (1) intervention feasibility and acceptability and (2) HU adherence measured in three ways: monthly percentage improvement toward HbF Personal best, the proportion of days covered (PDC) by HU, and self-report. Results: Twenty-eight dyads were enrolled, of which 89% were retained. Feasibility and acceptability were excellent. Controlling for group assignment and month of intervention, the intervention group improved percentage decrease from Personal best by 2.3% per month during months 0-4 (P = 0.30), with similar improvement in adherence demonstrated using pharmacy records. Self-reported adherence did not correlate. Dyads viewed CHWs as supportive of learning about SCD and HU, living with SCD, and making progress in coordinated self-management responsibility to support a daily HU habit. Most parents and youth appreciated text message HU reminders. Conclusions: The HABIT pilot intervention demonstrated feasibility and acceptability with promising effects toward improved medication adherence. Testing in a larger multisite intervention trial is warranted.

Heredia NI, Lee M, Reininger BM. Exposure to a community-wide campaign is associated with physical activity and sedentary behavior among Hispanic adults on the Texas-Mexico border. BMC Public Health. 2017 Nov 16;17(1):883. doi: 10.1186/s12889-017-4893-4.
Background: Despite evidence for the use of community-wide campaigns to promote physical activity, few evaluations of community-wide campaigns in Hispanic communities exist. This study assessed the associations of exposure to a community-wide campaign with physical activity and sedentary behavior among Hispanic adults living on the Texas-Mexico border. Methods: The intervention, Tu Salud ¡Si Cuenta! (Your Health Matters!; TSSC), included a newsletter, community health worker discussion, and TV and radio segments, which were conducted from 2005 to 2010. We matched an intervention (N = 399) and a control community (N = 400) on demographics and used a cross-sectional assessment in 2010 with randomly sampled adults from both communities. We collected exposure to the campaign, as well as physical activity and sedentary behavior with the International Physical Activity Questionnaire. We conducted bivariate analyses and multivariable logistic regression models to assess the association of TSSC exposure and its components with meeting moderate-to-vigorous intensity physical activity (MVPA) guidelines and exhibiting excessive sedentary behavior, controlling for covariates. Results: As compared to the control community, the intervention community has 3 times the odds of meeting MVPA guidelines (Adjusted OR [AOR] = 3.01, 95% CI = 1.85-4.88, p < .05) and 2 times lower odds of excessive sedentary behavior ((AOR = 0.46, 95% CI = 0.30-0.70, p < .05). Exposure in the intervention group to any component was associated with five times the odds of meeting MVPA guidelines (AOR = 5.10, 95% CI 2.88-9.03, p < .001) and 3 times lower odds of excessive sedentary behavior (AOR = 0.32, 95% CI 0.17-0.60, p < .001), compared with those unexposed in the control community. Exposure to newsletters, CHW discussions, and TV segments was associated with significantly lower odds of excessive sedentary behavior and higher odds of meeting MVPA guidelines. Exposure to radio segments was only associated with significantly higher odds of meeting MVPA guidelines (AOR = 4.21, 95% CI = 1.17-15.09). Conclusions: This study provides some evidence of the association of community-wide campaigns and its components in Hispanic communities with higher levels of MVPA and lower levels of excessive sedentary behavior.

Horton LA, Ayala GX, Slymen DJ, et al. A mediation analysis of mothers' dietary intake: the Entre Familia: Reflejos de Salud randomized controlled trial. Health Educ Behav. 2017 Dec 1:1090198117742439. doi: 10.1177/1090198117742439.
Aims: Examine intervention effects among mothers involved in a healthy eating randomized controlled trial. Furthermore, examine the mediating roles of individual and familial influences on observed outcomes. Methods: Between 2009 and 2011, 361 families were recruited; half were assigned to an 11-session community health worker-delivered family-based intervention targeting Spanish-speaking Latino families in Imperial County, California. The intervention was delivered over a 4-month period. Home visits and telephone calls were delivered approximately weekly, with tapering near the end of the intervention to promote independence from the promotora. In this article, mothers' self-reported dietary intake was the primary outcome. Evaluation measures were taken at baseline, 4 months, and 10 months. Results: Daily servings of fruits were higher among intervention versus control mothers (mean = 1.86 vs. mean = 1.47; effect size [ES] = 0.22) at 10 months post-baseline. Mothers in the intervention versus control condition also reported consuming lower percent energy from fat (mean = 30.0% vs. 31.0%; ES = 0.30) and a higher diet quality (mean = 2.93 vs. mean = 2.67; ES = 0.29). Mediators of improvements were behavioral strategies to increase fiber and lower fat intake, family support for vegetable purchasing, and decreased unhealthy eating behaviors and perceived family barriers to healthy eating. Discussion And Conclusion: Family-based behavioral interventions are effective for changing the skills and family system needed to improve diet among Latina mothers. Healthcare providers and other practitioners are encouraged to target skill development and foster a socially supportive environment.

Ingram M, Doubleday K, Bell ML, et al. Community health worker impact on chronic disease outcomes within primary care examined using electronic health records. Am J Public Health. 2017 Oct;107(10):1668-1674.
Objectives: To investigate community health worker (CHW) effects on chronic disease outcomes using electronic health records (EHRs). Methods: We examined the EHRs of 32 147 patients at risk for chronic disease from 2012 to 2015. Variables included contact with clinic-based CHWs, vitals, and laboratory tests. We estimated a mixed model for all outcomes. Results: Within-group findings showed statistically significant improvements in chronic disease indicators after exposure to CHWs. In health center 1, HbA1c (glycated hemoglobin) decreased by 0.15 millimoles per mole (95% confidence interval [CI] = -0.24, -0.06), body mass index decreased by 0.29 kilograms per meter squared (CI = -0.39, -0.20), and total cholesterol decreased 11.9 milligrams per deciliter (CI = -13.5, -10.2). In health center 2, HbA1c decreased by 0.43 millimoles per mole (CI = -0.7, -0.17), body mass index decreased by 0.08 kilograms per meter squared (CI = -0.14, -0.02), and triglycerides decreased by 22.50 milligrams per deciliter (CI = -39.0, -6.0). Total cholesterol of 3.62 milligrams per deciliter (CI = -6.6, -0.6) in health center 1 was the only improvement tied to CHW contact. Conclusions: Although patients' chronic disease indicators consistently improved, between-group models provided no additional evidence of impact. EHRs' evolution may elucidate CHW contributions moving forward.

Jacobsen AA, Maisonet J, Kirsner RS, Strasswimmer J. Applying the community health worker model in dermatology: a curriculum for skin cancer prevention education training. Int J Dermatol. 2017 May;56(5):567-570. doi: 10.1111/ijd.13514.
Background: Incidence of skin cancer is rising in Hispanic populations and minorities often have more advanced disease and experience higher mortality rates. Community health worker (CHW) programs to promote primary and secondary prevention show promise for many diseases, but an adequate training program in skin cancer prevention is not documented. We present a model for CHW specialty certification in skin cancer prevention for underserved, Hispanic communities. Methods: We designed a culturally appropriate CHW training program according to an empowerment model of education for skin cancer prevention and detection in underserved Hispanic communities. We partnered with a large nonprofit clinic in South Florida. Results: Nineteen CHWs completed the 2-h training course. After the course, 82.4% (n = 14) strongly agreed with the statement "I feel confident I can educate others on the warning signs of melanoma." Eighty-eight percent (88.2%, n = 15) strongly agreed that they felt confident that they could educate others on the importance of sun safety. One hundred percent (n = 19) answered each question about how the sun affects the skin correctly while 84.2% (n = 16) were able to identify the "ABCDEs" of melanoma. Nearly 90% strongly agreed with "I plan to change my personal sun safety behaviors based on what I learned today". Discussion: Our results indicate the successful transfer of information and empowerment to CHWs with high levels of confidence. Disease-specific "specialty certifications" are a component of effective CHW policies. An appropriate training tool for skin cancer education is an important addition to a growing list of CHW specialty certifications.

Justvig SP, Li J, Caravella G, et al. improving adherence to care recommendations using a community health worker (CHW) intervention with the pediatric medical home. J Community Health. 2017 Jun;42(3):444-452. doi: 10.1007/s10900-016-0275-6.
While CHW interventions improve health outcomes, evidence identifying specific domains of CHW-delivered support resulting in positive outcomes is limited. Our goals were to identify domains of CHW-delivered support that assist families with adhering to recommended pediatric care; and, to identify predictors of successful completion of an enriched medical home intervention (EMHI) using trained CHWs making home visits to provide health education and support positive health behaviors. We performed a prospective descriptive study of 88 families participating in a protocol-based EMHI. Completers (N = 46) finished the program with mutual agreement that the family can independently adhere to recommended clinical care. Non-completers (N = 42) were lost to follow-up or dropped out of the program before reaching this milestone. Using Grounded Theory, two trained coders evaluated CHW tasks recorded in an electronic database and classified these tasks across 17 domains. We assessed predictors of EMHI completion using logistic regression. The 88 EMHI participants were primarily <24 months of age (80 %), Hispanic (56 %), and Medicaid enrollees (67 %). Hispanic families (OR = 2.76, p = 0.04) and those with self-reported program goals to 'facilitate family's creation of a system to keep track of child's medical information' (OR = 3.11, p = 0.02) or a 'newborn-specific goal' (OR = 3.21, p = 0.04), such as feeding and safety tips, were more likely to complete the EMHI compared to their counterparts. The most consistent CHW tasks were supporting medical appointments, medication maintenance, and providing health education. CHW interventions designed to improve health behavior outcomes of 'at-risk' families, including Medicaid enrollees, may benefit from support in goal setting and strategies to systematically manage their child's medical care.

Kangovi S, Mitra N, Grande D, et al. Community health worker support for disadvantaged patients with multiple chronic diseases: a randomized clinical trial. Am J Public Health. 2017 Aug 17:e1-e8. doi: 10.2105/AJPH.2017.303985. [Epub ahead of print]
Objectives: To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. Methods: We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013-2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. Results: Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: -0.4 vs 0.0; body mass index: -0.3 vs -0.1; cigarettes per day: -5.5 vs -1.3; systolic blood pressure: -1.8 vs -11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs -0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 29.7% (P = .11). There were no differences in patient activation or self-rated physical health. Conclusions: A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for healthcare systems.

Lairson DR, Kim J, Byrd T, Salaiz R, Shokar NK. Cost-effectiveness of community interventions for colorectal cancer screening: low-income Hispanic population. Health Promot Pract. 2017 Dec 1:1524839917750815. doi: 10.1177/1524839917750815.
Objective: To assess the cost-effectiveness of interventions to increase colorectal cancer (CRC) screening among low-income uninsured Hispanics in El Paso, Texas. Method: Participants 50 to 75 years old who were due for screening, were uninsured and had a Texas address were randomized to promotora, video, or promotora and video interventions. High-risk participants were offered colonoscopy, while others were offered fecal immunochemical testing. A nonintervention comparison group was recruited from a similar Texas U.S.-Mexico border county. Screening was determined at 6 months post-intervention. Resources were tracked prospectively to determine cost. Incremental cost-effectiveness ratios were assessed with "intention to treat" methods. Uncertainty in the estimates was analyzed with sensitivity analysis and nonparametric bootstrap methods. Results: The interventions achieved screening rates of between 75% and 87% compared to 10% in the comparison group. The cost per participant ranged from $72 for group sessions to $93 for individual video sessions with video and promotora. The group video sessions cost $104 per additional person screened. Conclusion: The CRC screening interventions were effective in increasing CRC screening. Compared to the experience in the control county, the group-based video-only intervention was the most cost-effective CRC screening promotion intervention.

Litzelman DK, Inui TS, Griffin WJ, et al. Impact of community health workers on elderly patients' advance care planning and health care utilization: moving the dial. Med Care. 2017 Apr;55(4):319-326.
Background: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. Objective: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. Research Design: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation. Subjects: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white. Measures: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes. Results:  In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45-0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Conclusions:  Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home healthcare providers. Having ACP conversation is associated with a significant reduction in seeking urgent health care and in hospitalizations.

Luque JS, Logan A, Soulen G, et al. Systematic review of mammography screening educational interventions for Hispanic women in the United States. J Cancer Educ. 2018 Jan 12. doi: 10.1007/s13187-018-1321-0.
In the United States (U.S.), Hispanics experience breast cancer disparities. Breast cancer is the leading cause of cancer-related death among Hispanic women, and Hispanic women receive mammography screening at lower rates than some other ethnic groups. This low rate of screening mammography is associated with an increased risk for possible late-stage diagnosis and lower survival rates. Educational interventions could play a role in increasing screening mammography rates among Hispanic women. This systematic review synthesized the current literature on educational interventions to increase mammography screening among Hispanic women. The review included studies published between May 2003 and September 2017 with experimental and quasi-experimental interventions to increase mammography screening among Hispanics in the U.S. Five studies out of an initial 269 studies met the inclusion criteria for the review. All studies employed an interpersonal intervention strategy with community health workers, or promotoras, to deliver the mammography screening intervention. For each study, odds ratios (OR) were calculated to estimate intervention effectiveness based on similar follow-up time periods. The study ORs resulted in a narrow range between 1.02 and 2.18, indicating a low to moderate intervention effect for these types of interpersonal cancer education interventions. The summary OR for the random effects model was 1.67 (CI 1.24-2.26). Hispanics exhibit lower levels of adherence to screening mammography than non-Hispanic whites. Interpersonal cancer education interventions such as the use of promotoras may help to mediate the impact of barriers to receiving a mammogram such as low health literacy, deficits in knowledge about the benefits of screening, and low awareness of the availability of screening services.

Magana S, Lopez K, Machalicek W. Parents taking action: a psycho-educational intervention for Latino parents of children with autism spectrum disorder. Fam Process. 2017 Mar;56(1):59-74.
The increased prevalence of autism spectrum disorder (ASD) among Latino children, later diagnosis, limited access to bicultural specialist support, and worsened health outcomes when compared to non-Latinos points to the need for a culturally relevant parent education intervention. This pilot study examined the feasibility, acceptability, and preliminary outcomes of a culturally derived intervention, Parents Taking Action, for 19 Spanish-speaking mothers of children with ASD. This study introduces the Promotora de Salud Model of intervention delivery to the autism field. A mixed-methods design including one group pre- and posttest design and focus groups was used to evaluate the outcomes of PTA. We found that the intervention was both feasible to implement and acceptable to participants. We also found significant increases in empowerment-oriented outcomes for parents between pre- and posttest suggesting that the intervention is promising. Suggestions for future research and practice are offered.

Malcarney MB, Pittman P, Quigley L, Horton K, Seiler N. The changing roles of community health workers. Health Serv Res. 2017 Feb;52 Suppl 1:360-382.
Objective: To examine what different types of employers value in hiring community health workers (CHWs) and determine what new competencies CHWs might need to meet workforce demands in the context of an evolving payment landscape and substantial literature suggesting that CHWs are uniquely qualified to address health disparities. Study Design: We used a multimethod approach, including a literature review, the development of a database of 76 programs, interviews with 24 key informants, and a qualitative comparison of major CHW competency lists. Principal Findings: We find a shift in CHW employment settings from community-based organizations to hospitals/health systems. Providers that hire CHWs directly, as opposed to partnering with community organizations, report that they value education and training more highly than traditional characteristics, such as peer status. We find substantial similarities across competency lists, but a gap in competencies that relate to CHWs' ability to integrate into health systems while maintaining their unique identity. Conclusions: As CHW integration into healthcare organizations advances, and as states move forward with CHW certification efforts, it is important to develop new competencies that relate to CHW-health system integration. Chief among them is the ability to explain and defend the CHW's unique occupational identity.

Nelson K, Taylor L, Silverman J, et al. Randomized controlled trial of a community health worker self-management support intervention among low-income adults with diabetes, Seattle, Washington, 2010-2014. Prev Chronic Dis. 2017 Feb 9;14:E15. doi: 10.5888/pcd14.160344.
Introduction: Community health workers (CHWs) can improve diabetes outcomes; however, questions remain about translating research findings into practical low-intensity models for safety-net providers. We tested the effectiveness of a home-based low-intensity CHW intervention for improving health outcomes among low-income adults with diabetes. Methods: Low-income patients with glycated hemoglobin A1c (HbA1c) of 8.0% or higher in the 12 months before enrollment from 3 safety-net providers were randomized to a 12-month CHW-delivered diabetes self-management intervention or usual care. CHWs were based at a local health department. The primary outcome was a change in HbA1c from baseline enrollment to 12 months; secondary outcomes included blood pressure and lipid levels, quality of life, and healthcare use. Results: The change in HbA1c in the intervention group (n = 145) (unadjusted mean of 9.09% to 8.58%, change of -0.51) compared with the control group (n = 142) (9.04% to 8.71%, change of -0.33) was not significant (P = .54). In an analysis of participants with poor glycemic control (HbA1c >10%), the intervention group had a 1.23-point greater decrease in HbA1c compared with controls (P = .046). For the entire study population, we found a decrease in reported physician visits (P < .001) and no improvement in health-related quality of life (P = .07) in the intervention group compared with the control group. Conclusion: A low-intensity CHW-delivered intervention to support diabetes self-management did not significantly improve HbA1c relative to usual care. Among the subgroup of participants with poor glycemic control (HbA1c >10% at baseline), the intervention was effective.

Powell T, Yuma-Guerrero P. Supporting community health workers after a disaster: findings from a mixed-methods pilot evaluation study of a psychoeducational intervention. Disaster Med Public Health Prep. 2016 Oct;10(5):754-761.
Objective: Community health workers (CHWs) in disaster-affected areas are at risk for emotional distress, as they support others while they may be in the process of rebuilding their own lives. The Resilience and Coping for the Healthcare Community (RCHC) intervention was developed in response to the stress CHWs faced after Hurricane Sandy. The intervention uses psychoeducation to help participants identify common stress responses, recognize signs of job burnout, and utilize healthy coping strategies. Methods: A mixed-methods pilot of the RCHC intervention was conducted in 2013 with a convenience sample of staff from 6 federally qualified health centers (n=69). Validated measures of stress, coping, compassion fatigue and satisfaction, burnout, stress, and social provisions and a measure of perceived knowledge were administered at baseline, after the workshop, and at a 3-week follow-up. Semi-structured interviews were conducted with 10 randomly selected participants and were analyzed by using content analysis. Results: From baseline to the post-workshop assessment, perceived knowledge scores increased from 24.59 to 30.34, t(62)=5.16 (P<0.001), and acute stress scores decreased significantly from 10.53 to 6.78, t(64)=4.74 (P<0.001). Significant increases from baseline to the 3-week follow-up (n=45) were found for perceived knowledge (24.05 to 27.24; t(40)=5.37; P<0.001), and social provisions (27.34 to 28.39; t(44)=2.15; P<0.05). Conclusions: Our qualitative findings indicated that the respondents valued learning about common stress responses and incorporating coping as part of a daily routine. Team building and normalization of emotions were seen as ancillary benefits that would reduce stress levels in the workplace. In conclusion, the RCHC intervention shows promise and should be investigated further in experimental studies.

Pratt R, Ahmed N, Noor S, et al. Addressing behavioral health disparities for Somali immigrants through group cognitive behavioral therapy led by community health workers. J Immigr Minor Health. 2017 Feb;19(1):187-193. doi: 10.1007/s10903-015-0338-2.
To test the feasibility and acceptability of implementing an evidence-based, peer-delivered mental health intervention for Somali women in Minnesota, and to assess the impact of the intervention on the mental health of those who received the training. In a feasibility study, 11 Somali female community health workers were trained to deliver an 8-session cognitive behavioral therapy intervention. Each of the trainers recruited 5 participants through community outreach, resulting in 55 participants in the intervention. Self-assessed measures of mood were collected from study participants throughout the intervention, and focus groups were conducted. The 55 Somali women who participated recorded significant improvements in mood, with self-reported decreases in anxiety and increases in happiness. Focus group data showed the intervention was well received, particularly because it was delivered by a fellow community member. Participants reported gaining skills in problem-solving, stress reduction, and anger management. Participants also felt that the intervention helped to address some of the stigma around mental health in their community. Delivery of cognitive behavioral therapy by a community health workers offered an acceptable way to build positive mental health in the Somali community.

Roman LA, Zambrana RE, Ford S, Meghea C, Williams KP. Casting a wider net: engaging community health worker clients and their families in cancer prevention. Prev Chronic Dis. 2016 Sep 15;13:E130. doi: 10.5888/pcd13.160114.
Engaging family members in an intervention to prevent breast and cervical cancer can be a way to reach underserved women; however, little is known about whether family member recruitment reaches at-risk women. This study reports the kin relationship and risk characteristics of family members who chose to participate in the Kin Keeper(SM) cancer prevention intervention, delivered by community health workers (CHWs) via existing community programs. African American, Latina, and Arab family members reported risk factors for inadequate screening, including comorbid health conditions and inadequate breast or cervical cancer literacy. CHW programs can be leveraged to reach underserved families with cancer preventive interventions.

Sabo S, Allen CG, Sutkowi K, Wennerstrom A. Community health workers in the United States: challenges in identifying, surveying, and supporting the workforce. Am J Public Health. 2017 Dec;107(12):1964-1969.
Community health workers (CHWs) are members of a growing profession in the United States. Studying this dynamic labor force is challenging, in part because its members have more than 100 different job titles. The demand for timely, accurate information about CHWs is increasing as the profession gains recognition for its ability to improve health outcomes and reduce costs. Although numerous surveys of CHWs have been conducted, the field lacks well-delineated methods for gaining access to this hard-to-identify workforce. We outline methods for surveying CHWs and promising approaches to engage the workforce and other stakeholders in conducting local, state, and national studies. We also highlight successful strategies to overcome challenges in CHW surveys and future directions for surveying the field.

Shokar NK, Byrd T, Salaiz R, et al. Against colorectal cancer in our neighborhoods (ACCION): A comprehensive community-wide colorectal cancer screening intervention for the uninsured in a predominantly Hispanic community. Prev Med. 2016 Aug 26. pii: S0091-7435(16)30251-1. doi: 10.1016/j.ypmed.2016.08.039. [Epub ahead of print]
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Screening is widely recommended but underutilized, particularly among the low-income, the uninsured, recent immigrants, and Hispanics. The study objective was to determine the effectiveness of a comprehensive community-wide, bilingual, CRC screening intervention among uninsured predominantly Hispanic individuals. This prospective study was embedded in a CRC screening program and utilized a quasi-experimental design. Recruitment occurred from Community and clinic sites. Inclusion criteria were aged 50-75years, uninsured, due for CRC screening, Texas address and exclusions were a history of CRC or recent rectal bleeding. Eligible subjects were randomized to either promotora (P), video (V), or combined promotora and video (PV) education, and also received no-cost screening with fecal immunochemical testing or colonoscopy and navigation. The non-randomly allocated controls recruited from a similar county received no intervention. The main outcome was a 6-month self-reported CRC screening. Per protocol and worst-case scenario analyses, logistic regression with covariate adjustment was performed.784 subjects (467 in intervention group, 317 controls) were recruited; mean age was 56.8years; 78.4% were female, 98.7% were Hispanic and 90.0% were born in Mexico. In the worst-case scenario analysis (n=784) screening uptake was 80.5% in the intervention group and 17.0% in the control group [relative risk 4.73, 95% CI: 3.69-6.05, P<0.001]. No educational group differences were observed. Covariate adjustment did not significantly alter the effect. A multicomponent community-wide, bilingual, CRC screening intervention significantly increased CRC screening in an uninsured predominantly Hispanic population.

Spence Cagle C, Wells JN. Culturally sensitive care: enlisting community partners to meet Mexican American caregiver needs. Clin J Oncol Nurs. 2017 Feb 1;21(1):E1-E8.
Background: Culturally sensitive interventions are needed to assist Mexican American (MA) patients with cancer and their family members in managing their care, navigating the healthcare system, and decreasing disparities in healthcare outcomes for Hispanics with cancer. Objectives: The objectives of this study were to understand the meaning of culturally sensitive care for oncology clinic healthcare providers and to assess the usefulness and feasibility of the role of a promotora de salud to meet caregiver needs. Methods: This study involved focus groups of 18 diverse providers who provided data for qualitative analyses. Findings: The findings (themes) defined the facilitators of and barriers to culturally sensitive care and the perceived role of a promotora de salud to support the healthcare team and improve cancer care provided by MA caregivers. In addition, promotoras de salud can help reduce health costs by decreasing patient clinic visits.

The Medical and Research Librarians have selected these resources on the Promotor(a) or Community Health Worker.

CDC Resources for Promotores de Salud/Community Health Workers
Promotores de salud, also known as promotoras, is the Spanish term for “community health workers”. The Hispanic community recognizes promotores de salud as lay health workers who work in Spanish-speaking communities. The CDC has compiled helpful information for promotoras.

Community Health Workers: Recommendations for Bridging Healthcare Gaps in Rural America, a National Rural Health Association Policy Brief, February 2017.
This policy paper reviews select research findings on Community Health Worker (CHW) integration relevant to policymakers, considers challenges, and presents recommendations to incorporate the CHW model in rural communities to improve health outcomes, reduce health disparities and enhance quality of life for rural Americans. 

Community Health Worker (CHW) 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.

Diffusion of Community Health Workers within Medicaid Managed Care: A Strategy to Address Social Determinants of Health. Carolina Nkouaga, Arthur Kaufman, Charlie Alfero, and Claudia Medina, Health Affairs Blog. 

Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers. The Community Guide, March 2015.

Map on Community Health Worker Models. Dec. 2021, National Academy of State Health Policy.
This NASHP map and chart makes it easy for you to find information about various activities related to CHWs in the states. 

State Approaches to Community Health Worker Certification.
Each state that has developed a CHW certification program, however, has taken its own approach to setting requirements for certification and determining how to administer the program.