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A brief history
Community Health Workers (CHWs) are variously known as community health advisors, promotores/promotoras de salud, peer counselors, community outreach workers, peer educators, lay health workers and many other titles. The National Community Health Advisor Study (NCHAS) (Rosenthal et al., 1998) tabulated survey responses from over 150 programs and identified 66 distinct job titles.
Their history goes back at least several hundred years in developing countries, where specially-trained individuals in villages attended to a variety of needs: they have been called feldshers in 17th century Russia and “barefoot doctors” in China. The spread of “liberation theology” and popular education (as espoused by Paolo Freire and others) in the 20th century led to the creation of the formalized role of promotor(a) de salud (health promoter) in Latin America. Their role has been formally recognized by the World Health Organization since the 1970s, and by the American Public Health Association in 2001.
Federal support in the U.S. was led by the Migrant Act of 1962 and the Indian Health Service’s Community Health Representative (CHR) Program in 1968. In the late 1960s and early 1970s a “Great Society” program called “New Careers” pursued creation of CHW jobs as entry-level positions for career development. Interest re-emerged in the 1990s with initiatives by the CDC and HRSA. An important international landmark, which had ripple effects in the U.S., was the publication by the Hesperian Foundation of Donde No Hay Doctor (Where There Is No Doctor) in 1977, followed by Helping Health Workers Learn in 1982.
In the 1990s local and national groups began to re-examine the potential roles of CHWs. Publications by CDC and HRSA in the mid-90s documented CHWs' successes and pointed to a much greater potential impact on a variety of issues. The National Community Health Advisor Study (NCHAS) gave the most thorough overview of the field to date. A series of economic development studies by Seedco (see Bibliography) pointed to new ways of creating better-paying jobs for CHWs. Conferences organized by HRSA (1998) and the Family Health Foundation (2001) demonstrated substantial interest by state and federal agencies in expanding CHW roles.
Most importantly, local and regional networks of CHWs and CHW programs have begun to crop up, notably in Massachusetts, New York, New Jersey, Virginia, the southeastern states (Community Health Advisor Network) and the southwest (Lay Health Workers/Promotores National Network). Several national/regional regional support organizations have arisen, such as the Center for Sustainable Health Outreach (CSHO) and the Family Health Foundation (FHF).
CHWs are represented in the American Public Health Association (see APHA policy statement) as a special interest group (SPIG). The CHW SPIG newsletters can be located on the Web here.
Most recently, CHWs and other interested groups have begun working on a national association or network to represent the interests of all CHWs.
Issues
Important issues remain in defining
the CHW. For more on these issues, click here:
Definition issues>>
APHA
Policy
The American Public Health Association adopted a Policy
Statement at its 2001 annual meeting, "Recognition and Support for
Community Health Workers' Contributions to Meeting our Nation's Health
Care Needs." Click here to view the text of this statement:
APHA Statement>>
National
Rural Health Association
Link
to NRHA issue paper on CHWs>>
Healthvisions
Midwest Slideshow
Healthvisions Midwest is a church-sponsored nonprofit
in East Chicago, Indiana. They have an online PowerPoint presentation
describing CHWs and their potential in meeting local health needs.
Click
here>>
DOL Occupational Outlook Handbook
The US Department of Labor defines CHWs as part of an occupational category called "Social and Human Services Assistants." DOL expects this category to be one of the fastest growing in 2001-2010.
For more info go to the Occupational Outlook Handbook on the Web - click here>>
The
National Community Health Advisor Study (NCHAS)
and the WHO definition
Occupations may be defined by job titles, by skills applied in their execution, or by the duties and roles played by their practitioners. The NCHAS noted that from the earliest days, some key elements of the definition have remained. The World Health Organization (WHO) definition, adopted in 1987, included the following:
CHWs should:
- be members of the community where they work,
- be selected by the community,
- be answerable to the communities for their activities,
- be supported by the health system but not necessarily a part of its organization;
- and have a shorter training than professional workers.”
The WHO definition further identified central roles for CHWs in developing countries:
- Education on prevention and control of health problems
- Promotion of positive contributions to the community’s health (such as food and water supply, immunizations, maternal and child health)
- Prevention and control of common diseases
And two others less likely to be found in more developed countries:
- Treatment of common diseases and injuries
- Provision of essential drugs
These last two roles, however, may also be found in the U.S. in the work of the IHS Community Health Representatives in certain isolated rural areas, especially in Alaska.
The
ten essential services of Public Health
Public health serves communities and individuals within
them by providing an array of essential services. CHWs can help state
and local public health agencies to improve many of these services.
Essential services of public health
include:
1. Monitor health status to identify and solve community health problems
2. Diagnose and investigate health problems and health hazards in the
community
3. Inform, educate, and empower people about health issues
4. Mobilize community partnerships and action to identify and solve health
problems
5. Develop policies and plans that support individual and community health
efforts
6. Enforce laws and regulations that protect health and ensure safety
7. Link people to needed personal health services and assure the provision
of health care when otherwise unavailable
10. Research for new insights and innovative solutions to health problems
For a more complete definition of each of these services, and to see how states are evaluated in their performance of these services, see a special report, "National Public Health Performance Standards" at the American Public Health Association (APHA) web site - click here>>