Elsevier

Health Policy

Volume 80, Issue 1, January 2007, Pages 32-42
Health Policy

Community health worker training and certification programs in the United States: Findings from a national survey

https://doi.org/10.1016/j.healthpol.2006.02.010Get rights and content

Abstract

Objective

To analyze trends and various approaches to professional development in selected community health worker (CHW) training and certification programs in the United States. We examined the expected outcomes and goals of different training and certification programs related to individual CHWs as well as the community they serve.

Method

A national survey of CHW training and certification programs. Data collection was performed through personal interviews, phone interviews and focus groups. Data sources included public health officials, healthcare associations, CHW networks, community colleges, and service providers. Initial screening interviews resulted in in-depth interviews with participants in 19 states. We applied human capital theory concepts to the analysis of the rich qualitative data collected in each state.

Results

CHW programs in the U.S. seem to have been initiated mainly due to lack of access to healthcare services in culturally, economically, and geographically isolated communities. Three trends in CHW workforce development were identified from the results of the national survey: (1) schooling at the community college level—provides career advancement opportunities; (2) on-the-job training—improves standards of care, CHW income, and retention; and (3) certification at the state level—recognizes the work of CHWs, and facilitates Medicaid reimbursement for CHW services.

Conclusion

Study findings present opportunities for CHW knowledge and skill improvement approaches that can be targeted at specific individual career, service agency, or community level goals. Trained and/or certified community health workers are a potential new and skilled healthcare workforce that could help improve healthcare access and utilization among underserved populations in the United States.

Introduction

Community health workers (CHWs) – sometimes referred to as community health advisors, promotoras/promotores, navigators, community health aides, lay health workers, and many other titles – help individuals and groups in their own communities access health and social services and educate community members about various health issues [1], [2], [3]. CHWs have been part of a rapidly growing health, human services and social services workforce in the U.S. over the past decade. This observed growth is mainly due to intensified utilization of such culturally skilled workers within the Health Resources and Services Administration (HRSA) funded primary care programs as well as local not-for-profit public health initiatives [4], [5], [6]. Although we do not know the official number of CHWs working on the U.S. due to a lack of standard definition of CHWs, they are a part of a larger field of social and human services para-professionals with substantial growth capacity [7]. In the U.S. Public Health System, CHWs have been most engaged and successful in activities related to health promotion/prevention and education through their broad knowledge about the their own community culture, behaviors, and needs [1], [8], [9]. Today, CHWs in the U.S. offer health advice, assist with health insurance and housing, work as part of a research team, track health status of families in their service area, and inform health systems about how to improve the delivery of services [7], [10]. The growing role of the CHW as a member of a multi-disciplinary team engaged in culturally appropriate health and social services delivery has drawn attention to appropriate training and possible certification of CHWs in many U.S. states. Rising healthcare costs, continued access gaps among underserved populations, and the growing diversity of the U.S. population are all reasons for more intensive and structured training of the CHW and the possible expansion of the role of the CHW [1].

A review of large-scale CHW programs has shown improvement in equity of service delivery at low costs for underserved populations, but not necessarily consistent or significant health impact [11]. More than a decade ago, the General Accounting Office reached the conclusion that home visiting is an effective strategy for maternal and child health outcomes in hard to reach populations, and consideration should be given to utilizing and training “non-nurses” or para-professionals as home visitors [12]. Recently, the National Rural Health Association recognized the value of the CHW as a natural helper and link to health care services, and therefore encourages the development of CHW programs [13]. In 2002 the American Public Health Association published a resolution recognizing the value of CHWs in improving access to healthcare services in their communities and called for support for CHW programs in order to meet the Nation's health care needs [14]. The Centers for Disease Control and Prevention's Division of Diabetes Translation has recognized the effectiveness of community health workers in diabetes education and self-care, and recently recommended CHW program development, stronger support for CHWs within diabetes healthcare teams, and evaluation of CHW programs related to diabetes care [15]. All of these agencies have recognized the important role the CHWs can play in closing the healthcare access gaps, and therefore call for further development of CHW programs, including educational opportunities for CHWs and a well-established evaluation process.

Today, there appears to be a new trend towards standardizing training and certification of generalist CHWs, who traditionally have worked within their communities as volunteers. The goal in this paper is to explore the development of standardized training and certification programs in the U.S., and their potential workforce policy implications. The analysis of CHW programs in the 50 states is based on qualitative data from a national survey of CHW certification programs conducted in 2003 [16]. The two questions of interest in this paper are:

  • 1.

    What factors contributed to the development of CHW training and certification programs in the United States?

  • 2.

    What are some of the outcomes of increased standardized training and certification of CHWs?

Section snippets

Methods

The data for this analysis come from the CHW Certification and Training National Survey [16]. The purpose of this qualitative study was to provide a national overview of state policy and state involvement on certification of CHWs, and to analyze the potential effects of these policy trends on the sustainability and effectiveness of CHWs, local and regional programs and CHW organizations, and on the formal healthcare system. The primary informants in each state were state public health officials

Results

Results of in-depth interviews were analyzed for the following 17 states: Alaska, Arizona, California, Connecticut, Florida, Indiana, Kentucky, Massachusetts, Mississippi, North Carolina, New Mexico, Nevada, Ohio, Oregon, Texas, Virginia, and West Virginia. Based on the analytical framework, programs in these 17 states were categorized into three main categories: “state certification program” (certification or licensure by a state department or agency), “community college training” (certificate

Discussion

Our in-depth survey of the 17 states revealed that each state's CHW program has unique histories, foci, and approaches to improving the skills and knowledge levels of lay health workers. We have identified three major trends in the states: community college based training, on-the-job training, and state legislated certification. Most states have supported training programs at the community college and local agency levels, while a few have decided to implement training requirements and

Acknowledgements

Data are from the National Survey of CHW Certification funded by Grant No. 5-UIC-RH00033, through the Office of Rural Health Policy, Health Resources and Services Administration (HRSA), US Department of Health and Human Services. Data collection was performed through the Southwest Rural Health Research Center (SWRHRC); Catherine Hawes, Ph.D., Senior Investigator and Director of SWRHRC; Marlynn May, Ph.D., Principal Investigator.

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    An earlier version of this paper was presented at the Academy Health Annual Meeting, Workforce Special Interest Group in San Diego in June 2004.

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