THE EMERGING ROLE OF THE
COMMUNITY HEALTH WORKER
IN CALIFORNIA

Results of a Statewide Survey and San Francisco Bay Area Focus Groups
on the Community Health Workers in California’s Public Health System

THE EMERGING ROLE OF THE
COMMUNITY HEALTH WORKER IN CALIFORNIA

by
Mary Beth Love
Director, Center for Health Promotion
Kristen Gardner
Program Coordinator, CHW Certificate Training

1992

Funded by the California Department of Health Services

Health Promotion Section

TABLE OF CONTENTS

EXECUTIVE SUMMARY
A statewide survey was conducted to assess California’s Community Health Workers (CHWs) regarding employment and training patterns, race and ethnicity, core tasks, training needs and training program design. The survey was mailed statewide to 310 facilities including Health Department, Community Health Centers and Bay Area Hospitals. The overall response rate was 60% (N=185) with 78% response for Public Health Departments, 60% response from Community Health Centers and 45% response from Bay Area Hospitals. Of the facilities responding over half employ CHWs in some capacity. More than half of theses CHWs earn between $20,000 and $30,000/year. The majority of CHWs are Latino/Latina (49%) with 25% Caucasians, 11% African American, 12% Asian/Pacific Islanders, and 4% Native American. Most CHWs have a high school degree or less (45%). Although CHWs are involved in a variety of activities, the study found that the majority provide health advising, information, referrals, translation services and advocacy for their communities. They work primarily in the areas of STDs/HIV/AIDS, Maternal and Child Health/Perinatal, Family Planning and work with youth. Most facilities reported that they require or provide some training for their CHWs (90%), although the amount of training and its source (internal or external) vary. Forty-seven percent of respondents indicated they would send their CHWs to a certificate training program if offered; another 43% would need more information. Fifty-nine percent would or possibly would provide tuition support for such a training and 87% would or possibly would provide release time from work to support CHW training. The five most valued areas identified for a training curriculum were communication, interviewing, counseling, advocacy and referral skills.

The focus groups of CHWs and one group of CHW supervisors were conducted in the San Francisco Bay Area to provide more in-depth information on the role of CHWs in public health delivery. The CHWs reinforced the authors’’ understanding that many current CHWs are successful clients of the rehabilitation programs they now work for or are individuals who were recognized and hired because of the community organizing work that they were already doing as volunteers for their community (PTA, church, etc.). The importance of being a "people person" and having an intimate knowledge of the community one serves were also stressed. The sense of responsibility CHWs feel as a result of the trust invested in them by their community was a common theme and highlighted the need for accurate referral and other information. When asked to identify their role in the community the CHW defined themselves as the "glue" between their clinic and the community. The CHW supervisors identified the abilities of CHWs to work effectively with hard to reach clients and to design culturally viable community programs as most valuable for their organization. The supervisors felt that training for CHWs should have two foci: 1) training for CHWs in how to take care or their community; 2) training in how to take care of themselves in a job that can be stressful and even dangerous.

INTRODUCTION
The current problems confronting the field of Public Health in the urban centers of our nation are complex and interwoven. They include: institutional problems such as service fragmentation (1), lack of access and client alienation (2); social problems such as unemployment, undereducation, homelessness, family dysfunction, child abuse and neglect; and the prevalence of high risk behaviors such as alcohol, tobacco and other chemical dependency, unsafe sex practices, suicide and homicide. These problems have attracted the attention and concern of not only the American public but its politicians and a wide range of governmental and nongovernmental bodies as well, including foundations and other private-sector organizations. Both public and private groups have funded a wide range of programs to "fix" these problems. However, it is increasingly acknowledged that much of this funding has been targeted to single issues, and the consequent interventions have been less effective than if programs worked systematically to support and complement each other (3). In addition, not only are multiple resources required to effectively address the multidisciplinary challenges in public health, but no single program or complex of programs is likely to be effective without the support and involvement of the targeted community.

There is a growing recognition that many public health programs actually increase individuals' dependency on outside services, aid and authority rather than help communities and individuals to become more self reliant. This realization has resulted in an explosion of interest in community coalition building and empowerment and a community strengthening approach to public health care is now emerging. In these community-based programs a new kind of worker has begun to play a leading role--the community health worker (CHW). The community health worker, although active throughout a long history of international health care efforts, is a relatively new category of public health provider in the United States. Werner describes these workers as the voices for the "voiceless" poor. "Their goal is for health for all--but health that is founded in human dignity, loving care, and fairer distribution of resources and power (4)."

Serving as "culture brokers," CHWs are bridges between their community and the public health care system. They are indigenous to the community in which they work ethnically, socio-economically, and experientially. This "insider" orientation provides CHWs with a unique understanding of the culture and strength of the community they serve. Because they are trusted they can serve as effective conduits of information, resources, services and advice on how to access those services. They provide culturally and linguistically appropriate services and, if respected as a member of the health care team, can serve as invaluable assets in the development of culturally relevant public health care programs.

Internationally, CHWs have been part of the beginning attempts to provide basic health services for all by involving the community in their health care. The first systematic use of CHWs was the Barefoot Doctor program in China. Workers brought health care to rural populations and supported communities in identifying and solving their health problems. Some programs have similarly expansive goals, while others are more specifically targeted, like providing vaccines or family planning to a population. Both large-scale and small-scale projects have been developed across the world with varying goals and degrees of success.

As some United States health indexes are proving to be comparable to those of developing countries, there is a greater awareness of the need for a different approach to health care. In the 1960s there was a growth in the use of CHWs in the U.S. that has since subsided. There is currently, however, a growing attempt to reach the increasing numbers of immigrants and disenfranchised people of color through CHWs. Their unique ability to work effectively with "hard to reach" populations, many of which are both underserved and in great need, has the potential to be a cost-effective method of delivering public health care in these times of shrinking budgets.
California is currently facing a crisis that can be greatly relieved by CHWs. Both our State's urban and rural areas have seen unparalleled increases in refugee, immigrant, and disadvantaged populations. Many of these new State residents are non-English speaking and bring with them both a wealth of alternative health knowledge and skills and a plethora of public health needs. The State is also experiencing a financial crisis resulting in unemployment and reduced funds for public health services at this time of increasing need. Community Health Work can aid in providing both employment opportunities for indigenous community members and culturally sensitive public health care.

In the interest of developing recognition and a training program for Community Health Work in California, a statewide survey was conducted to investigate the extent of utilization of CHWs in the State, their ethnic profile, job responsibilities and training needs. Focus groups were also conducted with CHWs and CHW supervisors to provide an in-depth look at these questions and to address interest in a formalized CHW training program as well as perceptions of the barriers for CHWs to career mobility.

LITERATURE REVIEW
In the 1950s and 1960s public health was developing primary health care (PHC) as its priority (5,6). PHC was defined at a joint UNICEF-WHO conference as the bridge between existing health care services and communities in need; primary health care was said to be "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and their families in the community through their full participation and at a cost that the community and country can afford (7)." One of the tools used to meet the goal of PHC was the Community Health Worker (5,6,8,9). The rationale for the CHWs use was that they could reach communities and lead them to become involved in their health.

In a comprehensive review of CHWs, Berman concludes that there is much evidence that international small-scale CHW projects are effective, but that large systems have mixed results (8). He points to the underestimation of the importance of CHW training and supervision and the inadequacy of evaluation methods for CHWs. Suggestions in the literature for improving the process of Community Health Work include increasing the length of CHW trainings (10,11,12,13), providing a training for supervisors (14,15), and focusing on practical, not theoretical, content of training (11,14,15). In addition, it is suggested that community members be involved in the selection of CHWs to facilitate community cooperation (12,16).

For programs within the United States, the issue of CHW selection has been repeatedly identified as crucial to the effectiveness of a CHW program (17,18,19,20,21,22). It is essential to choose indigenous individuals who are motivated, truly interested in the community they work with, and have personal and professional stability. Qualities such as warmth, flexibility, and knowledge of the community are important. While having a background in the necessary job skills is helpful (19,20), it appears secondary to personal skills and experience.

Once CHWs are involved in a program, role clarification has been shown to help them imagine the nature of their work and to reduce friction with other allied health professionals (19,22). Co-workers and supervisors must understand, respect and empower CHWs in their role in order to maximize their effectiveness as part of the service team and as program planners (19,20,22). Giblin suggests that this can be facilitated by training CHW supervisors.

Most of the training programs reviewed consisted of classroom learning, on-the-job training and in-services to follow-up the original training (18,20,21,22,23). Giblin suggests that the training itself must preserve the indigenousness of the CHW by fostering natural skills and not imposing the health system's values and methods.
In one college based training program, trainees took regular college courses and participated in field work (18). Program evaluation pointed to the importance of a counselor and the need to provide classes for the trainee separate from the general student body. This project, along with three others (21,22,24), indicated that academic accreditation should be awarded to trainees to allow for greater career mobility. The recognition that some Community Health Workers may want to move on should not reduce the value of the work itself (25).

SURVEY METHOD
In assessing the need for, and viability of, certificate training for Community Health Workers, a survey was utilized to collect data relating to CHW employment and training patterns; race and ethnicity; core tasks within both clinic-based and outreach positions; interest in a formal training program; and opinions on a training program design. Provider groups likely to employ CHWs were identified and included community health centers, public health departments, and hospitals. The health centers and public health departments were located throughout California, while the hospitals included were in Northern and Central California only.

The survey process was based on Don A. Dillman's method as described in "Mail and Telephone Surveys: The Total Design Method (26)." Pilot questionnaires were first sent to 20 representative members of the groups targeted for the survey. All returned comments were considered and incorporated into the final draft as appropriate. The 10-page survey was then sent to 310 facilities. One week after the original mailing a reminder postcard was sent. Three weeks later a second copy of the survey was mailed to all facilities that had not yet responded. Two weeks after that a final postcard reminder was mailed.

The response rate overall was 60% (N=185). The response rate for the Community Based Health Centers was also 60% (N=98). Hospitals returned 45% (N=37), probably because the mailings were addressed to "Hospital Administration" rather than to an individual as with all of the Health Department and most of the Health Center packets. The response rate for Health Departments was 78% (N=50). This rate may have been higher because many Health Departments received two sets of mailings, one to the Public Health Officer and one to the Local Director of Health Education. There was likely a response selection bias based on employment of Community Health Workers; those who employ CHWs would be more likely to respond.

The survey encompassed both outreach and clinic-based community health workers. Community Health Outreach Workers (CHOWs) are considered to be workers whose primary tasks for the community are activities performed largely outside the clinic or agency (such as case finding, community organization, and community education). A Clinic-Based Community Health Worker (CBCHW) is someone whose tasks are performed largely within a clinic or agency (such as translation, health histories, or medical assisting). Profile information such as tasks, ethnicities and salaries are considered separately for CHOWs and CBCHWs in the results. The training needs of CHWs and the interest in a formal training program are also presented.

SURVEY RESULTS
Of the 185 facilities that responded, more than half (99, 54%) employ CHWs in some capacity. When this percentage is broken down into the two different categories--CHOW and CBCHW--42% of the entire sample report employing outreach workers and 40% report employing clinic-based workers. Community Based Organization reflected a similar profile with more than half employing CHW (40% CHOW and 44% CBCHW), but two-thirds of the County Health Departments (72%) employ CHWs while only 24% of the Hospitals do. Most of the Hospitals have outreach workers (22%) rather than clinic-based health workers (8%) (Figure 1). The actual number of CHWs represented was 846 Community Health Outreach Workers and 799 Clinic-Based Community Health Workers, although many of the workers function as both and are therefore counted twice.

PROFILE OF COMMUNITY HEALTH WORKERS
As described earlier, the survey elicited information about two types of CHW: CHOWs and CBCHWs. In this section the results of both types of worker will be presented and compared.
The outreach workers are disproportionately distributed among the facilities surveyed; the 39 Health Centers who employ CHOWs report employing a total of 200 CHOWs (average of 5 per facility), the 30 Health Departments who employ CHOWs

TABLE 2
ETHNICITIES OF CHWS BY FTE

Certifications are Awarded 33 40 16 50
Respondents who did not provide training were asked if they saw the need for a formal training. Sixty-nine percent report a need and 28% are not sure. Of all facilities with CHWs, 47% would send their current workers to a certificate training and only 10% would not. Of all respondents, 60% would employ CHWs with such a training, 15% would not and the 18% that did not answer were mostly facilities that do not currently

TABLE 6
ATTITUDES TOWARDS PROPOSED TRAINING

primarily homeless women. The seventh CHW has worked in a variety of areas including in cancer and perinatal. In this section the main questions and CHW responses are presented.

What led you to become a CHW?
For many, initial involvement as CHWs seems to arise from their situations. Some of the CHWs were successful clients of rehabilitation programs who were then recruited to work with their communities. Others were recognized for their natural abilities to organize their peers and were offered a salary for work similar to what they were already doing. Both of these types of CHWs felt strongly about their "chance to be able to give back to the community."

One CHOW said, "My history is being a recovering addict, and to go back out and work with the same type of clients that I was a part of makes it easy to communicate." With their intimate knowledge of their clients' situations they enjoy bringing vital information about health to a community they care about. One woman felt particularly committed to her job when she realized it made a significant difference in the lives of the homeless women she helped.

What personal characteristics do you believe are important in being an effective CHW?
In discussing what personal characteristics are important to being an effective CHW, both groups of CHWs first mentioned "being a people person." One woman who works with homeless women defined that as, "Having no problems with meeting people, having time, listening and enjoying. Doing it not just because it's your job, but because you really enjoy it." This must be coupled with knowing the community you work with. This allows one to communicate, to be sensitive to the clients' needs, to be able to share personal experiences and to be culturally informed.

Some participants also believed that CHWs should be culturally similar to their clients, although others believed it was helpful but not necessary. Most people did agree that a CHW must be a model. One man said, "My community is small, almost everyone knows each other.... I have to show them how good I am... before I talk about not smoking; if they see me smoking it is not effective."

What skills do you believe are important in being an effective CHW?
One group felt very strongly that a certain resourcefulness is a necessary characteristic for an effective CHW. A CHW's contact with a client may be the only opportunity for education and referrals, so it must be done well. This means having the information on hand, referring the individual appropriately, giving good and honest information and being able to find what the client needs. One AIDS outreach worker said, "If you were to name three things an outreach worker needs to be, the person needs to be a counselor, they need to be an advocate, and they need to be a politician."

Other skills that are important are self-awareness, communication, patience, being able to say "I don't know," persistence, and being able to approach people. As a CHOW it is important to keep informed about the community by reading the local paper and updating one's knowledge of resources. Some felt that it is important to know about diseases in depth. A long-time CHW agreed that such specific knowledge is critical, but that it is possible to gain such knowledge on the job.

What is your role in your organization? Why is it important?
CHWs fill many important roles. Mainly they are the "glue" between their organization and the community. They provide a bridge between the professionals and clients and are able to communicate with both. They share information with the community about health and resources while also being the "eyes of the clinic." The expertise they bring to the clinic is an understanding of diversity and how to treat clients in a respectful and effective way.

One of the valuable aspects of CHWs is that they are effective. A CHOW who works with homeless women related a story:
I did not think of my job as CHOW as important. I was even ready to tell my boss, "What do you need me here for? What do I bring to the program that's unique?" until those two ladies came up to me just out of the blue... and said, "I have two months clean and sober and my baby was delivered clean and sober"... and they said, "We never would have done it without you."

One CHW recognized that "our performance is quite important, not only for the people, but for the organization we work for. We bring in the clients and (the clinic is) funded again." CHWs are especially able to bring in diverse clients, currently an important Public Health goal and a focus of many grants.

What do you need to do a better job?
Working as a bridge between worlds is a very stressful and demanding position. One group of CHWs expressed a need for more support in order to do a better job. Supervisors can be more supportive by trusting and respecting the CHWs and being available to listen or answer questions. They felt a need for greater access to emotional support, including from other CHWs and other staff members. A couple of participants mentioned the need for teamwork within their organization so that there is continuity in services. The need for ongoing informational updating was stressed: "If we could have one day a week just to be updated.... That would give us a break on the emotional side" as well as provide necessary continued education.

How were you trained?
Many of the CHWs receive ongoing education, but it is sporadic and it is often the only training they are given. CHWs are sent to pertinent seminars and conferences if there are funds available and if release from work is feasible. These provide good updates and a chance to network. Another main training technique is on-the-job observation and performance. This allows for studying other workers' techniques and creating a unique style. CHWs liked both of these methods of learning, but wanted training and more regular ongoing access to them.

How are you supervised? What do you wish your supervisor knew?
The CHWs that participated all report very positive relationships with their supervisors, although they were aware of the difficulties that can arise in the CHW-supervisor relationship. The CHWs indicated that their supervision was "loose" and mostly consisted of written daily logs and regular meetings. The nature of the job requires this looseness and a great deal of trust and honesty. To facilitate this the supervisor and CHW need to establish a good rapport and the supervisor needs to be familiar with outreach work and able to discern quality performance. One CHW who feels she is blessed with a great supervisor said:

A supervisor who is supervising outreach workers should know where that outreach worker is coming from. Depending on the work there are all kinds of instruments to tell if you are doing the work.... That's her job to figure out whether the information that we are putting down we are making up or if it something that is really happening.What are some suggestions you have regarding the training we are proposing, specifically concerning recruitment and reducing barriers to the training?
One group discussed particulars about the proposed training. They said that potential CHWs may be found among parents who are involved in the schools, clients of programs who hire CHWs, and clients of GAIN (Greater Avenues to Independence). To be an attractive program it must be in an accessible location, provide support like childcare and transportation and be able to place CHWs in jobs. Possible schedules for a training were also discussed. A few people expressed a preference for a spread-out schedule, rather than intensive classes. They felt that such a schedule would reduce the stress level, be easier to take in and put into practice, and might make it easier to get release time.
One aspect of the training that is controversial is whether or not it should be considered a "Step-to-College." Everyone agreed that providing a certificate of completion and college credits would be beneficial for those who wanted to leave the field or even change place of employment within the field. The concern is that the focus on "moving on" will detract from the validity of the CHW position. One woman who has been a CHW for over 26 years said, "We are unique and we want it to be recognized as a profession."

SUPERVISORS
Seven supervisors attended who work with a diverse set of communities. Most either currently work in direct service or have previously done so. Their CHW programs ranged from the well established to the very new and had a range of CHW responsibilities.

Why do you have CHWs? What value do they have for your organization?
The primary asset CHWs bring is their relationship to the community. They can offer education to people not easily reached otherwise and can bring back vital information about these clients. One supervisor emphasized:

Our population is completely mistrustful of anything having to do with the system.... Often they are not willing or sometimes not even able to communicate with "health professionals." In our case all three of our CHWs are formerly homeless, all are mothers, two were substance abusers, so they've been there.... They have an entree that, no matter how together and progressive the rest of us are, we just don't have.

CHWs are an integral part to designing appropriate programs. While professionals can assess needs and set goals for improving health, they need input from CHWs to translate the research into a viable and effective approach. One supervisor that works with the Asian population said that his community health assistants "come from the community. It is their understanding of their community that enhances our program and directs us. So we are very interested in how they approach specific goals that we generate out of the needs that we assess."

If we devised a training for supervisors what should it include?
This discussion addressed, in particular, what should be included in a training for supervisors that might help them work more successfully with their CHWs. Learning how to be a good mentor was suggested. This included helping the CHW set personal goals, being available, and listening well. Also, helping the CHW set personal and professional boundaries was mentioned. One supervisor added, "Help them get in touch with where they're coming from because you know it's going to effect how they do their work."

Supervisors, like CHWs, feel that knowing the work and experience of CHWs is the most crucial aspect. It is important to be in touch with "very real people with very real problems" and know what it is the CHW does in working with these people. With this knowledge supervisors can learn to act as bridges between the ways of the community and the ways of the organization.

What changes in your organization would help with the training and supervision of CHWs?
Successful supervising includes working with the rest of the organization to create a supportive environment for CHWs. The changes supervisors would like to see in their organizations to aid in this include a better understanding and greater openness to CHWs on the part of the other staff. The staff needs to value CHWs and their input and find ways to work together. They also felt that being linked to other facilities with CHWs would support and validate their CHWs. There is also the ever-present need for more resources that would make everyone's job easier.

How do you currently train CHWs and how would you ideally train them?
It has already been mentioned that supervisors must have trust in their CHWs. Part of this relies on the ability to select CHWs who are trustworthy and really a part of the community with a deep commitment to their work. The selection of CHWs is also important in that some skills are not easily taught, such as community leadership and being a "people person."

Once hired, most CHWs are trained by observing on-the-job, going to external trainings or conferences, and attending ongoing inservices. A couple of supervisors said that they train the CHWs themselves and one said that people are brought in from outside organizations to carry out the training. One woman spoke of the haphazardness of her agency's training.

Participants felt that an ideal training would deal with two levels: the information CHWs need for the community and the information they need for themselves. Training can provide some of the same support a mentor should, including empowerment for the CHWs in setting their goals and finding a way to reach them. For example, CHWs can be introduced to the range of options available to them. The information they need for the community includes understanding current information within one's field, but also general information in any area. One supervisor feels, "The more grounded you are, the more you can handle anything that comes your way, because outreach workers are going to hear it all."

Would a certificate CHW training be helpful?
Supervisors felt overall that such a training would be beneficial for those CHWs not ready to do the teaching themselves. It would help individual CHWs in pursuing their interests by providing a certificate and credits. CHWs could become more well rounded, possibly including an academic background in program development. It would also provide a chance to interact with other CHWs and affirm their knowledge for themselves. A couple of concerns were mentioned. One person felt that it was important that their job fit into the training. A larger concern was regarding the possibility of a mandated certificate and the barriers that it would create.
In giving us suggestions about a training, supervisors were quite aware of barriers. As with the CHWs, they mentioned having an accessible schedule, childcare, and transportation. They also addressed the fact that many CHWs are both outreach and clinic-based workers, so that a general training for both would be helpful and appropriate. One supervisor pointed out that for those who do not work in both capacities it is still important to understand what both positions do so that they can better follow their clients.

CONCLUSION
A community-strengthening approach to public health care is emerging in response to the interwoven and complex problems threatening the public's health. This approach is based on an ecological model of health that looks not only at the traditional indicators of access to health care or prevalence of behavioral risk factors but also recognizes the economic and sociological determinants of community health. It focuses on collaboration, coalition building and empowerment and has as one of its pivotal new players the Community Health Worker. The survey and focus group results reported in this paper found that in California the majority of the State's Public Health Departments and Community Health Centers currently employ CHWs (54% to 75%). The majority of such workers have a high school degree or less and the vast majority are people of color. Serving as "culture brokers" these workers form the link between the State's health care services and its burgeoning multiethnic communities. Our survey shows that CHWs are involved with their communities providing predominantly health education, information/referrals and translation services in the areas of AIDS/STDs, Maternal and Child Health/Perinatal, Family Planning, Tobacco Control and work with youth.

Information was also collected on the training needs of this valuable and growing workforce. The majority of the respondents currently conduct some type of training for their CHW staff. However, in both the survey and in the focus groups the majority of those asked reported that they would or possibly would take advantage of a more formalized training curriculum for the State. Skills training in the areas of: communication, interviewing, counseling, advocacy, referrals, screening and medical terminology were a few of the most frequently listed curriculum content areas identified.

In the focus groups it was stressed that CHWs are essential members of the health care team. They are not always awarded the recognition and value that their work deserves, however. It is believed by many focus group participants that more systematic training of CHWs can increase the recognition they receive, provide CHWs with greater employment options, and improve the quality of their work. It was also felt that training that involved CHW supervisors or co-workers would facilitate the integration of CHWs and increase team efficacy.

The emerging emphasis in Public Health Care transcends the traditional models of intervention. It is community based and focuses on collaborative strategies to empower community residents. Central to this emerging ecological model of public health delivery, Community Health Work has great potential to improve primary health care outcomes, to provide employment opportunities for indigenous community members, to support community members to help shape the programs that effect their communities and to provide a career ladder in public health to indigenous community leaders who are interested.

REFERENCES

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BIBLIOGRAPHY

CAPTIONS/FIGURES
Figure 1
CHWs, CHOWs, and CBCHWs employed by Health Care Centers, Public Health Departments, and Hospitals.
Figure 2
CHOWs employed in full or part time capacity by Health Facility, and by topical area.
Figure 3
Health areas in which CBCHWs are being employed by percentages in each focus area, and by full/part time status.
Figure 4
Curriculum content areas indicated by level of importance for a CHW training program.

Table 1
Average Salaries of CHWs by FTE.
Table 2
Ethnicities of CHWs.
Table 3
Activities CHOWs Perform.
Table 4
Activities CBCHWs Perform.
Table 5
Profile of current CHW training.
Table 6
Attitudes Towards Proposed Training