Community Health Worker Community Health Worker (CHW):(CHW):

A New Profession in the A New Profession in the Health Care Workforce?Health Care Workforce?

Bita A. Kash, MBA, FACHE Bita A. Kash, MBA, FACHE

Marlynn L. May, PhD, MDiv Marlynn L. May, PhD, MDiv

Ming Tai-Seale, PhD, MPHMing Tai-Seale, PhD, MPH

Southwest Rural Health Research CenterSchool of Rural Public Health, Texas A&M University Health Science Center

TAMU 1266College Station, Texas 77843-1266

(979) 458-0653www.srph.tamushsc.edu/srhrc

Project Support - Acknowledgement

Projects funded by a grant (5-UIC-RH00033) through…

Federal Office of Rural Health Policy (ORHP)

Health Resources and Services Administration (HRSA)

Data collection through the Southwest Rural Health Research Center (SRHRC)

Catherine Hawes, PhD, Senior Investigator and Director of SRHRC

Community Health Workers Community Health Advisors Promotoras Indigenous Workers Lay Health Workers Community Health Aides Family Service Workers

Research Objective1.1. To apply economic perspective of To apply economic perspective of

market failure (Arrow, 1963), and market failure (Arrow, 1963), and human capital theory (Becker, 1962) to human capital theory (Becker, 1962) to study the history and development of study the history and development of certification programs for CHWs in the certification programs for CHWs in the United States.United States.

2.2. To explore potential workforce To explore potential workforce implications.implications.

Background• Classical models of the process of

professionalization rooted in sociology:

• Schein (1972)

• Caplow (1954)

• Sociologists have been increasingly incorporating economic models and literature to expand sociological sub-fields such as labor markets and human capital since the 1970s (Baron and Hannan, 1994).

BackgroundWhy economic models can be an alternative approach in examining emerging allied health professions:

1. These occupations developed largely as a result of an unmet need in the healthcare market, and

2. They are less likely to pursue autonomy, which is the problematic component of the professionalization models based in sociology.

Framework of Analysis Results of a national survey of CHW

programs are presented based on:

1. The framework of “market failure” (Arrow, 1963) when analyzing the history and initiation of CHW programs in the U.S., and

2. The “human capital theory” (Becker, 1962) when discussing goals and impact of the CHW programs.

Research Hypothesis 1.1. States are moving towards standardization States are moving towards standardization

of training and certification of CHWs in of training and certification of CHWs in order to increase and improve CHW order to increase and improve CHW utilization and income potential. utilization and income potential.

2.2. CHWs are an emerging new class of CHWs are an emerging new class of professionals in the healthcare workforce professionals in the healthcare workforce market, and therefore will experience an market, and therefore will experience an increase in earnings potential.increase in earnings potential.

National Study: Data Sources

1. Informants: public health officials, healthcare associations, CHW networks, community colleges, and service providers.

2. Internet Resources: state legislative websites, and CHW program websites.

National Study: Methodology

Initial Screening

50 States

In-depth Interviews

19 States Typology of CHW

Programs

Selection Criteria

Atlas.ti

Snowball ProcessQualitative Analysis

Summary of Results• 19 states have existing CHW certification and/or 19 states have existing CHW certification and/or

training programs.training programs.

• Most of these states have training programs at Most of these states have training programs at

community colleges and direct service agencies.community colleges and direct service agencies.

• Only 9 of these programs are supported by the Only 9 of these programs are supported by the

state either financially or through other means.state either financially or through other means.

• AK, and TX are the only states administering a AK, and TX are the only states administering a

certification program for CHWs. certification program for CHWs.

Summary of Results• AZ, CA, NM, KY, and MA are considering state-level AZ, CA, NM, KY, and MA are considering state-level

certification for CHWs. certification for CHWs.

• OH, NC, and NV have established standards for training OH, NC, and NV have established standards for training

of CHWs at the state level, but do not administer of CHWs at the state level, but do not administer

certification programs. certification programs.

• Agency level training appears to be most prevalent in Agency level training appears to be most prevalent in

“special case” states that utilize specialized lay health “special case” states that utilize specialized lay health

workers in areas such as prenatal care, heart disease, workers in areas such as prenatal care, heart disease,

cancer, mental health, and AIDS prevention.cancer, mental health, and AIDS prevention.

Level of Support for CHW Programs

OH

NC

NV

AK

IN

AZ

CA

HI

KY

TX

NM

OR

FL

CTMA

MS

WVVAMD

State Legislated/Required by State

Supported by State No State Support/Agency Based

Typology of CHW Programs

Certification Training Special Cases

State Legislated or Required AK, TX OH, NC,

NV IN

Supported by State (financial or other)

AZ, CA, HI, KY, MA, NM,

VA

CT, FL

Not Supported by State OR MS, MD,

WV

Sta

t es in

Bold

: Pro

gra

m Im

pact is La

rger th

an R

egio

nal

Conclusions:Emergence of CHW Programs Initiatives can be described as society Initiatives can be described as society

taking steps to correct dissatisfaction taking steps to correct dissatisfaction with the competitive equilibrium achieved with the competitive equilibrium achieved in the market (Arrow, 1963).in the market (Arrow, 1963).

All programs reported a common theme in All programs reported a common theme in the history of their programs, and the the history of their programs, and the initial creation of the CHW occupation: initial creation of the CHW occupation: unmet need and lack of access to healthcare unmet need and lack of access to healthcare

services in culturally, economically and services in culturally, economically and geographically difficult to reach communities.geographically difficult to reach communities.

Conclusions:Goals and Impact of ProgramsThree prevalent themes on training and certification:Three prevalent themes on training and certification:

• Schooling at the community college level: Schooling at the community college level: provides career advancement opportunities into provides career advancement opportunities into nursing and social work.nursing and social work.

• On-the-job training at the agency level: On-the-job training at the agency level: improves standards of care, outcomes, secures improves standards of care, outcomes, secures CHW income, and improves retention of CHWs.CHW income, and improves retention of CHWs.

• Certification at the state level: recognizes the Certification at the state level: recognizes the value of CHWs, enhances reimburseability of value of CHWs, enhances reimburseability of CHWs, and improves self-esteem and self worth CHWs, and improves self-esteem and self worth of CHWs.of CHWs.

What CHWs are saying about Certification“What is power? Health is power. Money is power. This is why I

am participating in the certification program. If you wish to be a volunteer, that’s fine. I’ve been a volunteer, too. This certification will help us get paid for out work. I am told that I am one of the best paid promotoras, but I don’t think I earn that much…”

Lorenza Zuniga, Promotora, El Paso, TX

“I’ve been a migrant farmworker since I was nine-years-old. Promotoras are from the community, they help the community because they want to do this and love to help. As a volunteer, I did not think about compensation or recognition. But now things have changed. We all need to survive in this world…”

Graciela Camarena, Promotora, Mercedes, TX

Policy Implications Improve the vertical mobility and career Improve the vertical mobility and career

advancement of CHWs by subsidizing advancement of CHWs by subsidizing education (community college approach).education (community college approach).

Provide stable jobs and incomes for CHWs by Provide stable jobs and incomes for CHWs by supporting the reimbursement of trained and supporting the reimbursement of trained and certified CHWs (on-the-job training and state certified CHWs (on-the-job training and state certification approach).certification approach).

Depending on what a state department of health Depending on what a state department of health or federal health agency attempts to achieve in or federal health agency attempts to achieve in the healthcare workforce supply. the healthcare workforce supply.

References:Arrow, K. J. (1963). "Uncertainty and the Welfare Economics of

Medical Care." American Economic Review 53(5): 941-973.

Baron, J. N. and M. T. Hannan (1994). "The Impact of Economics on Contemporary Sociology." Journal of Economic Literature 32: 1111-1146.

Becker, G. S. (1962). "Investment in Human Capital: A Theoretical Analysis." The Journal of Political Economy 70(5): 9-49.

Caplow, T. (1954). The Sociology of Work. New York, McGraw-Hill Book Co.

Rosenthal, E. L. (1998). A Summary of National Community Health Advisor Study. Baltimore, MD, Annie E. Casey Foundation.

Schein, E. H. (1972). Professional Education: Some New Directions. New York, McGraw-Hill Books Co.

Thank You!

Southwest Rural Health Research Center

School of Rural Public Health, Texas A&M University Health Science Center

TAMU 1266College Station, Texas 77843-1266

(979) 458-0653

www.srph.tamushsc.edu/srhrc