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
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 report a total
of 328 (average of 11 per facility), while the 8 Hospitals who employ CHOWs
report a total of 318 (average of 40 per facility). This is pertinent when
looking at the data analyzed in terms of facilities rather than number of
workers. CBCHWs are more proportionately distributed: 513 work in 43 Health
Centers (average 12 per facility), 255 in 28 Health Departments (average 9 per
facility), and 31 in 3 Hospitals (average 10 per facility).
The salaries for
CHWs tend to be low. For CHOWs overall, 36% of facilities pay under $20,000 per
year for the equivalent of a full-time position and 55% pay $20-30,000. Health
Centers generally pay less than either Health Departments or Hospitals.
Clinic-based workers seem to have an even lower salary rate with 47% earning
under $20,000 per year and only 6% earning more than $30,000 (Table 1).
TABLE 1
AVERAGE SALARIES OF CHWS
TABLE 2
ETHNICITIES OF CHWS BY FTE
The education
level of CHWs and their potential as candidates for Bachelors Degrees were
requested in order to assess what educational preparation might be needed or
wanted. Overall, 8% have no degree, 37% have a High School Diploma or
Equivalent, 7% have an Associate Degree and 15% have a Bachelor's Degree. Of
these, 24% are considered candidates for Bachelor's Degrees.
RESPONSIBILITIES AND FIELDS OF WORK
The survey was
not only meant to create a demographic profile of CHWs, but also to discern the
realm of work CHWs do. In this section the activities of the CHOW and the CBCHW
will be presented.
COMMUNITY HEALTH OUTREACH WORKERS (CHOWs)
Respondents were
asked to indicate which tasks CHOWs performed from a list of seven choices. The
two activities noted by more than ninety percent of respondents were
Information and Referral (94%) and Health Education (91%). Translation was also
reported by the majority of respondents (73%). Over one half of the respondents
reported Advocacy (66%) and Case Finding (55%) as activities that their CHOWs
are performing, while only Community Organization and Home Health Visits were
reported as less frequently performed activities with each activity being
reported by 48% of the sample. The different types of facilities seem to have
varying emphases within the outreach worker position. Health Centers (N=39)
mostly marked Information and Referrals (100%) and Health Education (97%), with
Translation (69%) and Advocacy (64%) also getting high scores. CHOWs in Health
Departments (N=30) primarily provide Information and Referrals (97%), Health
Education (90%) and Translation (90%), with Advocacy (77%), Case Finding (73%),
and Home Health Visits (67%) as important elements. Hospitals (N=8) emphasized
Home Health Visits (75%), with Health Education (63%) and Information and
Referrals (50%) as secondary emphases (Table 3).
TABLE 3
ACTIVITIES CHOWS PERFORM
Respondents
designated other activities their CHOWs performed. Four facilities mentioned
counseling. Case management, providing transportation, basic clinical tasks and
educating other staff were each noted twice under "Other."
In order to
record the approximate time CHOWs spend in each topical area, respondents were
asked to list the number of CHOWs that work full-time or part-time in
each area.
Overall the largest area for full-time workers is HIV/AIDS/STDs (26%), with
significant numbers in Perinatal (19%), Family Planning (13%), Nutrition (13%),
Tobacco Control (11%) and Tuberculosis (9%) (Figure 2). Health Centers had
full-time workers primarily in HIV/AIDS/STDs (34%), Nutrition (24%) and Family
Planning (20%). Health Departments focused more on Perinatal (32%),
HIV/AIDS/STDs (19%), Tuberculosis (18%) and Tobacco Control (17%). The
Hospitals reported CHOWs in only Perinatal (83%) and Alcohol and Drug Abuse
(17%). In addition, 88 CHOWs were said to work in Home Health full time and 27
in General or Primary Care.
The profile of
part-time work showed similar patterns, except that there was a more equal
distribution of workers in the areas overall. Youth and Aging have
significantly more part-time workers than full-time. Health Centers apply 18%
of their 146 part-time CHOWs in Alcohol and Drug Abuse, compared to 3% of their
103 full-time positions. Health Departments also have 18% of their part-time
workers in Alcohol and Drug Abuse, while no individuals work full-time in that
area. As with full-time work, under "Other" Home Health was the most
frequently mentioned category (48 positions). Cancer was reported to have 15
part-time positions.
CLINIC BASED COMMUNITY HEALTH WORKERS
(CBCHWs)
A different list
of activities was provided when asking about CBCHW tasks. Translation was the
most frequently marked task (91%), with Health Education (88%), Information and
Referral (84%), and Client Intake (83%) showing as significant categories.
Hospitals were fairly consistent in differing substantially from Health Centers
and Health Departments in the frequency of indicating tasks, although only 3
Hospitals completed this question (Table 4). Twelve respondents noted Clinical
Skills as an additional task category. Six added front desk related tasks.
Billing/Medi-Cal and Client Follow-Up were each noted 5 times.
Overall,
full-time CBCHWs are found mostly in four areas: Family Planning (28%),
HIV/AIDS/STDs (23%), Youth (20%) and Perinatal (16%). Health Centers have a
similar profile since they comprise almost 80% of these positions. Full-time
CBCHWs at PH Departments are mainly in Perinatal (40%), Nutrition (24%) and TB
(14%). The only Hospital CBCHW indicated as working full time on one issue is
employed in Perinatal (Figure 3). Thirteen CBCHWs were said to work full time
in general or primary health under "Other."
TABLE 4
ACTIVITIES CBCHWS PERFORM
The part time
CBCHW work has a similar profile to the full time one, except that Immunization
and TB are also significantly represented. PH Departments mostly employ part
time in Perinatal (25%), Family Planning (20%), Immunization (20%) and
HIV/AIDS/STDs (16%). One Hospital employs 23 CBCHWs that split their time
between all of the areas. Most likely these 23 individuals are general or
primary health care workers. Under the "Other" section, 67 part time
CBCHWs were identified as primary or general health workers.
Training
Practices
Most facilities
require or provide training for their CHWs (90%). The trainings are done
primarily internally (39%) or both internally and externally (42%). Hospitals
are the only facilities that train primarily externally (50%). The length of
training was hard to discern since the majority of respondents reported that it
varies. Many descriptions included on-the-job training tailored to the
individual, which probably explains the inability to report the hours of
training. About one-third of facilities indicated that trainees received
certifications. Some specifically indicated that these were received from
external trainings (Table 5).
TABLE 5
PROFILE OF CURRENT TRAINING
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
To discern a
schedule for the training that would be accessible to individuals, respondents
were asked to choose the most preferred schedules from a list of possibilities.
Overall, the most popular choice was for two evenings per week for six months.
All of the facilities rated this choice highly. The second choice was for one
day per week for six months. While Health Centers and Health Departments
agreed, Hospitals were split over all of the choices, showing a real preference
only for the first.
When asked about
topics considered important for a training program, Communication was rated the
highest (3.85 on a 4 point scale: 4=Very Important, 1=Not Important).
Interviewing, Health Counseling, Advocacy and Referrals were also rated highly.
The lowest overall rating was 2.85 for Community Organization, which is still
close to an "Important" rating (Figure 4). Under the
"Other" space, Cultural Diversity was listed 11 times. Various
professional skills were added a total of 10 times, including time management,
career building, and separating personal and professional issues.
FOCUS GROUP RESULTS
In late October
three focus groups were held to discuss issues regarding the training and
supervision of Community Health Workers. These were meant to address topics
that could not be adequately covered in a written questionnaire. Invitations
were sent to local survey respondents that currently employ CHWs. Two sessions
were held with CHWs and one session with CHW supervisors. Twelve people were
admitted into each group, with the assumption that some would not show. A sum
of twenty-five dollars was offered to CHWs as reimbursement for lost work time
and transportation expenses. Each session was one and one-half hours. The
discussions were facilitated by asking some preformed questions and exploring
the responses as appropriate. The two CHW sessions were presented with many of
the same questions. A few issues were pursued only in one group or the other.
The responses of CHWs have been combined in the first discussion section. The
session with CHW supervisors addressed some of the same issues as with the CHWs,
but from a different viewpoint, thus it is summarized separately.
COMMUNITY HEALTH WORKERS
The first group
had 11 participants who were diverse in ages and ethnicities. Two worked mainly
in AIDS outreach, while for 2 others AIDS prevention was a significant part of
their work. Three worked with the Asian communities as translators and health
educators. Five CHWs spent much of their time in clinics, while the others
spent most of their time in the community. In the second group there were three
long-time CHWs who worked mostly in Maternity Child Health or Family Care
within a clinic or doing home visits. Three other participants combined
outreach and clinic-based work with
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.
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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