This page provides a selected list of current articles from the research literature of interest to stakeholders in the Promotor(a) or Community Health Worker Training and Certification Program. A promotora/community health worker is defined here as a person who, with or without compensation:
provides cultural mediation between their communities and health and human service systems;
provides informal counseling and social support;
provides culturally and linguistically appropriate health education;
advocates for individual and community needs;
assures people get the services they need;
builds individual and community capacity;
or provides referral and follow-up services.
For further information on the following articles contact the Medical and Research Library at library@dshs.state.tx.us or call 512-776-7559. For further information on promotoras/es and community health workers in Texas, contact chw@dshs.state.tx.us; call 512-776-3500, or visit the Promotor(a) or Community Health Worker Training and Certification Program website, part of the Office of Title V and Family Health, at http://www.dshs.state.tx.us/mch/chw.shtm.
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may also not be accessible to people with disabilities. The links were working at the time they were created.
Selected Current Journal Articles and Reports
[See a more comprehensive bibliography of articles on community health workers.]
Alfaro-Trujillo B, Valles-Medina AM, Vargas-Ojeda AC. Profiles, perceptions and motivations of community health workers of NGOs in a border city of US-Mexico. Journal of Community Health. 2011 Sep 29. [Epub ahead of print]
To analyze the profile, perceptions and motivations of Community Health Workers (CHWs) from non-governmental organizations (NGOs) in the border city of US-Mexico and to describe the type of community interventions they perform, we surveyed 121 CHWs from 9 NGOs participating in a monthly meeting between May and July of 2009. Each participating CHW answered a structured questionnaire. Furthermore, two focus groups were held, in which 10 and 8 CHWs participated, respectively. Qualitative and quantitative analyses were carried out on the data obtained. 70% of the CHWs had 9 years or less of formal education. With respect to community work, 61% volunteered between 1 and 5 h weekly; only 40% received some form of economic support. The most commonly reported activities were distribution of informational materials (59.5%) and promotion of health fairs (52.9%). Analysis of focus group discussions led to the development of four conceptual categories: personal development, motivation, perception of their community participation and institutional relationship. Some of the testimonies are "…just because the people do not respond does not mean we give up. No, we must work, persist, promote and raise awareness of the people…", "…when they compensate us, it is not really a payment. We are there because we get results, we do it happily… It is voluntary…" CHWs are an important human resource for communities. Institutions focusing on primary care should view these community players as social capital, which could improve the effectiveness of prevention strategies and achieve greater coverage of health services.
Balcazar H, Alvarado M, Ortiz G. Salud para su corazon (health for your heart) community health worker model: community and clinical approaches for addressing cardiovascular disease risk reduction in hispanics/latinos. J Ambul Care Manage. 2011 Oct-Dec;34(4):362-72.
This article describes 6 Salud Para Su Corazon (SPSC) family of programs that have addressed cardiovascular disease risk reduction in Hispanic communities facilitated by community health workers (CHWs) or Promotores de Salud (PS). A synopsis of the programs illustrates the designs and methodological approaches that combine community-based participatory research for 2 types of settings: community and clinical. Examples are provided as to how CHWs can serve as agents of change in these settings. A description is presented of a sustainability framework for the SPSC family of programs. Finally, implications are summarized for utilizing the SPSC CHW/PS model to inform ambulatory care management and policy.
Boyd RC, et al. Screening and referral for postpartum depression among low-income women: a qualitative perspective from community health workers. Depression Research and Treatment. 2011:320605 (2011).
Postpartum depression is a serious and common psychiatric illness. Mothers living in poverty are more likely to be depressed and have greater barriers to accessing treatment than the general population. Mental health utilization is particularly limited for women with postpartum depression and low-income, minority women. As part of an academic-community partnership, focus groups were utilized to examine staff practices, barriers, and facilitators in mental health referrals for women with depression within a community nonprofit agency serving low-income pregnant and postpartum women. The focus groups were analyzed through content analyses and NVIVO-8. Three focus groups with 16 community health workers were conducted. Six themes were identified: (1) screening and referral, (2) facilitators to referral, (3) barriers to referral, (4) culture and language, (5) life events, and (6) support. The study identified several barriers and facilitators for referring postpartum women with depression to mental health services.
Brownstein JN, et al. Community health workers "101" for primary care providers and other stakeholders in health care systems. Journal of Ambulatory Care Management. Vol. 34(3):210-20 (Jul-Sep 2011).
Today's ambulatory care providers face numerous challenges as they try to practice efficient, patient-centered medicine. This article explains how community health workers (CHWs) can be engaged to address many patient- and system-related barriers currently experienced in ambulatory care practices. Community health workers are frontline public health workers who serve as a trusted bridge between community members and health care providers. Among their varied roles, CHWs can educate and support patients in managing their risk factors and diseases and link these patients to needed resources. As shown in this overview (CHW 101), including CHWs as members of multidisciplinary care teams has the potential to strengthen both current and emerging models of health care delivery.
Farrar B, et al. Growing your own: community health workers and jobs to careers. Journal of Ambulatory Care Management. Vol. 34(3):234-46 (Jul-Sep 2011).
This article evaluates the implementation and impact of 5 workforce development programs aimed at achieving skills upgrades, educational advancement, and career development for community health workers (CHWs). Quantitative and qualitative case study data from the national evaluation of the Jobs to Careers: Transforming the Front Lines of Health Care initiative demonstrate that investing in CHWs can achieve measurable worker (eg, raises) and programmatic (eg, more skilled workers) outcomes. To achieve these outcomes, targeted changes were made to the structure, culture, and work processes of employing organizations. These findings have implications for other health care employers interested in developing their CHW workforce.
Ferguson WJ, et al. Developing community health worker diabetes training. Health Education and Research. 2011 Sep 15. [Epub ahead of print]
We designed, implemented and evaluated a 48-hour training program for community health workers (CHWs) deployed to diabetes care teams in community health centers (CHCs). The curriculum included core knowledge/skills with diabetes content to assist CHWs in developing patient self-management goals. Our qualitative evaluation included pre/post-knowledge outcomes and encounter data from the field. CHWs and their supervisors were interviewed providing qualitative outcome data of the training process and program implementation. There were statistically significant increases in the scores of CHWs' self-reported knowledge in 8 of 15 curricular domains. Qualitative analysis revealed that CHWs preferred skill-based and case-based teaching, shorter training days but more contact hours. CHWs reported that pre-deployment training alone is insufficient for successful integration into care teams. CHW supervisors reported that CHC's readiness to accept CHWs as members of the care team was as important to successful deployment as training. With respect to implementation, supervision by social workers was deemed more successful than nursing supervision. Field data showed that patient encounters lasted less than 30 min and self-management goals focused on appointment keeping, diet, exercise and glucose testing. Integration and analysis of qualitative and descriptive field data provide an opportunity to continuously evaluate the effectiveness of implementation.
Herman AA. Community health workers and integrated primary health care teams in the 21st century. Journal of Ambulatory Care Management. Vol. 34(4):354-61 (Oct-Dec 2011).
Community health workers are an integral part of many healthcare systems. Their roles vary and include both the socially oriented tasks of natural helpers and specific constrained tasks of health extenders. As natural helpers, community health workers play an important role in connecting public and primary care to the communities that they serve. As primary health care becomes more patient-centered and community-oriented, the natural helper roles that include trust, rapport, understanding, and the ability to communicate with the community take on an increased significance. Community health workers are effective and make the health care system more efficient. In some states, the community health worker has become a more formal member of the integrated primary health care team, and it is in this role that she or he provides structured linkages between the community, the patient, and the health care system. The effective community health workers are strongly embedded in the communities that they serve; they have clear supervision within the health care system; they have clearly defined roles in the health care system; and they are well trained and have a defined system of advancing their education and roles within the health care system.
Johnson CM, Sharkey JR, Dean WR. It's all about the children: a participant-driven photo-elicitation study of Mexican-origin mothers' food choices. BMC Womens Health. Vol. 11(1):41 (Sep 26 2011).
Background: There is a desperate need to address diet-related chronic diseases in Mexican-origin women, particularly for those in border region colonias (Mexican settlements) and other new destination communities in rural and non-rural areas of the U.S. Understanding the food choices of mothers, who lead food and health activities in their families, provides one way to improve health outcomes in Mexican-origin women and their children. This study used a visual method, participant-driven photo-elicitation, and grounded theory in a contextual study of food choices from the perspectives of Mexican-origin mothers. Methods: Teams of trained promotoras (female community health workers from the area) collected all data in Spanish. Ten Mexican-origin mothers living in colonias in Hidalgo County, TX completed a creative photography assignment and an in-depth interview using their photographs as visual prompts and examples. English transcripts were coded inductively by hand, and initial observations emphasized the salience of mothers' food practices in their routine care-giving. This was explored further by coding transcripts in the qualitative data analysis software Atlas.ti. Results: An inductive conceptual framework was created to provide context for understanding mothers' daily practices and their food practices in particular. Three themes emerged from the data: 1) a mother's primary orientation was toward her children; 2) leveraging resources to provide the best for her children; and 3) a mother's daily food practices kept her children happy, healthy, and well-fed. Results offer insight into the intricate meanings embedded in Mexican-origin mothers' routine food choices. Conclusions: This paper provides a new perspective for understanding food choice through the eyes of mothers living in the colonias of South Texas -- one that emphasizes the importance of children in their routine food practices and the resilience of the mothers themselves. Additional research is needed to better understand mothers' perspectives and food practices with larger samples of women and among other socioeconomic groups.
Johnson D, et al. Community health workers and Medicaid managed care in New Mexico. Journal of Community Health. 2011 Sep 28. [Epub ahead of print]
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
Kenya S, et al. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature. HIV Medicine. Vol. 12(9):525-34 (Oct 2011).
Objectives: Highly active antiretroviral therapy (HAART) has transformed HIV infection into a manageable chronic illness, yet AIDS mortality among ethnic minorities persists in the USA. HAART nonadherence is associated with increased HIV viral load, low CD4 cell count and racial disparities in HIV outcomes. While there is no universal consensus on how to improve medical adherence in HIV-positive populations, the community health worker (CHW) model is emerging as an effective strategy to overcome barriers to HAART adherence. Although utilized in international settings, there is little evidence regarding the effects of CHWs on HIV outcomes in the USA. Methods: We performed a comprehensive search from May 2010 to November 2010 to identify studies carried out in the USA that utilized CHWs to improve HAART adherence and measured HIV viral loads and CD4 cell counts to assess intervention effects. Sixteen studies met the inclusion criteria and were reviewed for this article. All studies reported clinical HIV outcomes. Results: Interventions that lasted at least 24 weeks, provided frequent contact with participants, and focused on medication management were associated with improved HAART adherence, as indicated by reduced HIV viral load and increased CD4 cell count. Conclusions: Compared with current standards of care, CHW programmes may offer a practical and cost-effective alternative to improve HAART adherence, which may lead to reduced HIV viral load and increased CD4 cell counts among HIV-positive populations in the USA.
Martin MA, et al. Evaluation of an asthma medication training program for immigrant Mexican community health workers. Progress in Community Health Partnerships: Research, Education, and Action. Vol. 5(1):95-103 (Spring 2011).
Background: Community health workers (CHWs) are frontline public health workers who connect immigrant communities with health care services. Although CHW asthma interventions have been shown to improve some outcomes, their ability to change medication adherence remains unclear. Objective: Our goal was to determine if intensive asthma medication training resulted in objective improvements in asthma medication instruction abilities for immigrant Mexican CHWs. Methods: Eleven CHWs participated in a 15-hour training course conducted in only Spanish. The course covered asthma pathophysiology, reliever and controller medications, medication technique, and self-management skills. Before and after the training, CHWs completed a written asthma knowledge test and were tested on medication delivery technique using a demonstrator metered dose inhaler (MDI), spacer, and dry powder inhaler (DPI). After the training, CHWs performed a standardized role play to assess their ability to deliver medication instruction. At follow-up evaluations, the CHWs described benefits and weaknesses of the training. Results: Before the training, the median correct medication technique scores were: MDI = 25%, spacer = 0%, and DPI = 0%. After the training, the median scores were: MDI = 69%, spacer = 64%, and DPI = 67% (p < .01). On the role plays, all CHWs were scored as "Demonstrates adequate understanding of a complicated skill" and four were "Ready for the field on a clinical trial." The CHWs described specific application of training skills during the subsequent delivery of an asthma intervention. Conclusion: This training and follow-up evaluation provide objective evidence of improved asthma medication knowledge, delivery technique, and instruction abilities in immigrant Mexican CHWs. With proper training, CHWs can assist families to understand and correctly use complicated asthma medications.
Murphy M, Matos S. Building relationships and changing lives: a community health worker story. Journal of Ambulatory Care Management. Vol. 34(4):375-6 (Oct-Dec 2011).
Maria Murphy is a community health worker in the south Bronx, an impoverished underprivileged neighborhood of largely Latino and African American communities along with smaller ethnic minority groups. Having come to New York at 13 years of age from her native Puerto Rico, Maria held numerous jobs while supporting her family and completing her education. Maria soon got a position as a community health worker and discovered purpose in her work. Her work with people she serves has been called a labor of love by her clients. Maria describes it as her passion. This is her story.
Otiniano AD, et al. Supporting Latino communities' natural helpers: a case study of promotoras in a research capacity building course. Journal of Immigrant and Minority Health. 2011 Sep 8. [Epub ahead of print]
Promotores have unique access to underserved and hard-to-reach Latino communities facing health disparities. Although promotores are involved in community change, they rarely receive training that gives them the skills to be partners in research. We present a case study of promotoras who participated in a research capacity building course focused on assessing community health needs. Data comes from course application surveys, follow-up notes, and narratives from qualitative phone interviews of eight promotoras. Content analysis drawing from grounded theory was conducted to identify and describe emerging themes. Four themes emerged as promotoras discussed their experience learning basic research skills and teaching others: (1) challenges, (2) support, (3) building capacity, and (4) using research. Promotores play an important role in the health of Latino communities and are increasingly asked to participate in research processes; however they have few opportunities for training and professional development in this area. Capacity building opportunities for promotores need to be tailored to their needs and provide them with support. Fostering collaboration between promotores and partnering with local community-based organizations can help facilitate needed research skill-building among promotores.
Tataw DB, Bazargan-Hejazi S, James FW. Health services utilization, satisfaction, and attachment to a regular source of care among participants in an urban health provider alliance. Journal of Health and Human Services Administration. Vol. 34(1):109-41 (Summer 2011).
This study examines the effect of a provider alliance on service utilization, satisfaction, self efficacy, and attachment to a regular source of care for participating low income urban children and their families. The use of Physician Assistants and community health workers to expand community outreach, primary care services, pediatric sub-specialty care, and service coordination within and between care settings improved health services utilization, satisfaction with health services, parental self efficacy in navigating the health care system for their children, and service convenience for an at-risk population. Also, the use of Physician Assistants to provide pediatric sub-specialty services did not have a negative effect on parental satisfaction with a child's care. Parents were slightly more satisfied with services received from a Physician Assistant in comparison with the physician sub-specialists in cardiology and nephrology clinics.
