A Report of The Community Health Worker Training Program,
a joint program of San Francisco State University,
Department of Health Education and City College of San Francisco, Health Science Department
Community Health Workers:
Who Are They and What Do They Do?
A Regional Labor Market Study -Survey of Eight Counties in the San Francisco Bay Area, 1996
"Opportunities are expanding for these front line health care professionals..."
"The widespread incorporation of CHWs into the health care delivery system offers unparalled opportunities to improve the delivery of preventive and primary care to America's diverse communities."
Pew Health Professions Commission
CHW Training Program
Department of Health Education
San Francisco State University
1600 Holloway Avenue
San Francisco, CA 94132
Phone: (415) 338-3034
Fax: (415) 338-7948
In recent years there has been an upsurge of interest in Community Health Workers. CHWs are community members who serve as front line health care professionals. They generally work with the underserved and are indigenous to the community in which they work--ethnically, linguistically, socio-economically and experientially. The paper presents the results of a survey of 197 systematically selected health care providers in eight Bay Area Counties. The survey was conducted to ascertain the number of CHWs in the field and to get a profile of who they are and what they do. We found that 25% of the health care providers in these eight counties hire CHWs. The hiring projections indicate that opportunities are expanding for these front line professionals, with the majority of growth being in Public Health Departments and Community Based Organizations (CBOs). The majority of CHWs are women (66%) of color (77%) with a high-school degree or less (58%). Forty-four percent earn an annual salary of $20,00 to $25,000 with 30% making more than $25,001. HIV/AIDS/STD and Maternal and Child Health/Perinatal are the two major content foci of CHW work. Our data supports the Pew Health Professions Commission's assessment that CHWs are an increasingly important way to extend primary and community health care.
Introduction and Background
In recent years, many innovative community health promotion and primary health care programs have utilized community members in a front line outreach capacity. There role is referred to by many names, including: Community Health Worker (CHW), Lay Health Advisor (LHA), Community Health Representative (CHR) and Public Health Aide (PHA). Working mainly with underserved communities, these health workers serve in a variety of capacities, from functioning informally as volunteers, to having more formal roles as front line health care professionals. There is not an agreed-upon set of skills for these health workers nor is there a clear definition of their role.
Serving as "culture brokers" between their community and the health care system, they are indigenous to the community in which they work--ethnically, linguistically, socio-economically, and experientially. 1 This "insider" orientation provides these workers with a unique understanding of the culture and strength of the community they serve. 1,2,3,4 Because they are trusted they can serve as effective conduits of information, resources, services and advice on how to access those services. If respected as members of the health care team, these frontline workers can play an invaluable role in delivering culturally appropriate cost effective health care. 1,2,3,4,5,6
The focus of this paper is the Community Health Worker, whose role is generally considered to be more formal and professional than the Lay Health Advisor. Lay Health Advisors as described by Eng and Young 7 are lay helpers "to whom others naturally turn for advice, emotional support and aid. They provide informal, spontaneous assistance which is so much a part of everyday life that its value is often not recognized." The CHW is broadly defined by the Pew Health Professions Commission "as community members who work almost exclusively in community settings and who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate care." 8 Although they share many of the same roles as lay health workers, Community Health Workers are typically not volunteers; they are employees in the health care system. The growing need for personnel within the health care system who can provide medical and cultural translation, health education, information and referrals, intake and eligibility services, case management and advocacy to diverse patient populations has formalized the CHW position in many health care settings. This article will describe the functions and attributes of the Community Health Worker based on the findings of a systematic eight-county survey of the San Francisco Bay Area in 1996.
The value of incorporating community members on community and primary health care teams has been appreciated for some time. In the 1950s and '60s, the Public Health Service determined that primary health care was its priority. Primary health care was defined at a joint UNICEF-WHO conference as the "bridge between existing health care services and communities in need". 9-11 One of the strategies used to meet the goal of primary health care was the employment of Community Health Workers. 9,10,12,13 The theoretical rationale for the use of CHWs in primary health care stems from the body of literature which points to the important influence of an individual's and a community's peer network in health decision making. 7,14-21
The Pew Health Professions Commission cites a resurgence of Community Health Workers in the 1990s. 22 This can be attributed to a number of factors. The first is the massive structural change in the U.S. health care system. 8,22-24 The salient trends driving reform focus on both the delivery and the financing of health care. Delivery systems are reorganizing to make prevention and primary care their emphasis and to move to lower-cost delivery settings (ambulatory care, home care) with less expensive providers. Further, the move towards managed care, with reimbursement provided in capitated monthly payments, means a shift from a cost unaware, fee-for-service system to a cost-conscious one. In many states Medicaid patients are being shifted to managed-care settings. 23,25
A second national trend affecting the renewed interest in Community Health Workers is the increasing diversity of the U.S. population. The nationality, ethnicity and linguistic make-up of this country has changed more dramatically in the past decade than at any time in the twentieth century. 26 For example, by the year 2000, one third of the population nationally will be people of color. California is often referred to as a "bell-weather" state for the nation as a whole. 27 In our state, half of the population will be Asian or Latino by the year 2000. The 1990 Census found that 33% of Asian/Pacific Islanders and 28% of Latinos in California were linguistically isolated. 28 In one metropolitan area in California, for example, 1% of the registered nurses are Latina while in many areas up to 65% of patients are Latino/a. 29 Additionally, California is the most diverse state in the nation, making it a matter of great complexity to bridge the language and culture gap between patients and health professionals who remain overwhelmingly monolingual and white. For instance, there are 120 languages spoken in the county of Los Angeles alone. 36
While the ultimate effects of these changes on the quality and accessibility of health care are yet to be seen, the emergence of Community Health Workers as an important asset to the health care team is being widely acknowledged. After reviewing a substantial body of research, the Pew Health Professions Commission concluded that "the widespread incorporation of CHWs into the health care delivery system offers unparalleled opportunities to improve the delivery of preventive and primary care to America's diverse communities." 8 In addition, the Centers for Disease Control published a two-volume series which annotates the research literature describing and evaluating the use of CHWs/Lay Health Advisors. 30
The contributions of CHWs to primary and preventive services are well documented. Many studies have shown the ability of CHWs to do effective preventive work, reduce cultural and linguistic barriers to care, help patients successfully navigate in complex health systems, and improve the quality and cost-effectiveness of care. After an extensive literature review, Witmer et al. cited 28 studies in the U.S. showing CHW success in: increasing access to prenatal care and other preventive care services, linking mentally ill and HIV infected people to needed services; increasing detection of breast and cervical cancer; increasing rates of immunization; decreasing low birth weight and infant mortality; controlling hypertension; and facilitating smoking cessation. 8 The Kaiser Commission on the Future of Medicaid cited an important series of studies that compares health outcomes of care given in a traditional medical care setting with care given in a community-responsive setting including use of CHWs. Care given in the more community-responsive setting yielded better health outcomes. 31
The unnecessary use of costly emergency room services is a major financial drain on health providers. One large hospital in New York found that 80% of pediatric emergency admissions were not emergencies, while primary care clinics were underutilized. To address this problem the hospital employed CHWs to help families connect with primary care. Non-urgent emergency room visits by adults decreased by 42% and broken appointment rates at primary-care clinics dropped from 50% to 11%. Patient medical care usage shifted from high use of emergency rooms and low use of clinics to high use of clinics and low use of emergency rooms. 32
There are other social benefits from the role of CHWs in the health care workforce. The profound changes taking place in health care are being paralleled by an equally profound transformation in the labor market. Entry level manufacturing and industrial jobs that have traditionally provided a ladder out of poverty for low-skilled individuals have all but disappeared. They have been replaced by service-sector jobs, few of which offer a family-supporting wage, full-time employment, benefits or a career path. 25
Health care is one of the fastest-growing sectors of the U.S. labor market according to the U.S. Bureau of Labor Statistics. Between 1990 and 2005, the health care industry is expected to provide more than 25% of all new jobs. Many of these occupations are considered entry level for largely unskilled persons, offering both living wages and career opportunities. Of the 30 occupations projected to show greatest growth by 2005, 11 are in the health field and five are entry level. 33 Community Health Worker jobs provide career opportunity and advancement for low income people without strong academic credentials.
According to the Pew Health Professions Commission, although the benefits of CHWs have been recognized in relation to the needs of the poor and underserved, there are several barriers to the use of such workers by the health care delivery system as a whole. First among these barriers is the lack of a standard definition and conceptualization of who Community Health Workers are and what they do. Limited data exists on the number of CHWs in the field, how they are used, what is their scope of work or how they are funded. 8,22 To address this barrier, this article presents the results of a systematic survey of health care providers in eight counties in Northern California to gather descriptive data on the roles, backgrounds and working conditions of CHWs.
A mail and telephone survey was conducted of health care providers in eight Northern California counties. The objectives of the survey were to determine: a) the proportion of health care employers in the population that employ Community Health Workers; b) the total number of CHWs employed; c) the number of CHWs projected to be hired in the next three years, to enable a projection of demand for CHWs in the overall population; d) a profile of CHW positions describing kind of work and level of pay and training; e) a profile of CHWs in regards to education, ethnicity and gender; and f) the barriers to wider employment of CHWs.
A stratified random sample was drawn from the population of health care service providers in eight San Francisco Bay Area counties in Northern California. This population was stratified by type of health care organization including HMOs, Private Hospitals, National Organizations, County Health Departments, and Community Based Organizations/Clinics. (CBOs/Clinics include non-profit and for-profit clinics or other health agencies that offer direct care.) Random samples of approximately 50% were drawn from the HMO, Private Hospital, National Organization, and CBO/Clinic lists. Because of the small number of County Health Departments, all were included to ensure adequate sampling.
Footnote on Research Methods: Each organization was contacted for a preliminary screening to determine if the organization employs or plans to employ CHWs and, if so, who was the best individual within the organization to describe their role and job opportunities. Eligible respondents were considered organizations that currently employed at least one CHW or intended to hire at least one in the next three years.
The survey was sent to the individuals identified in the preliminary phone calls. Because of the absence of a formal or widely recognized job description for CHWs, a definition of CHWs was included in the survey and referred to whenever there was a question as to who qualified as a CHW within an agency. Two weeks after the initial mailing all non-respondents were called. Three weeks after the initial mailing all non-respondents were sent another copy of the survey and a follow-up cover letter. In the third through fifth weeks after the initial mailing, all non-respondents were called five more times. After six attempts to reach potential respondents by phone, efforts were terminated.
In the process of the original phone contact we found that only one HMO (one of the two with MediCal contracts) and only one private hospital employed CHWs. Given this, the Private Hospital category was dropped from the study. Because of the increasing trend to contract MediCal services to HMOs, we chose to include the HMOs with MediCal contracts in our results. Figure 1 provides an overview of the sampling and survey methods employed.
Projections for future demand for CHWs were calculated from the 57 responses projecting hiring in the next three years. The size of the overall population was adjusted for the calculations to account for the unusable listings. This helps to preserve a conservative approach to projecting hiring. For each category of organizations the sampling variance and appropriate weighting factor were calculated. These were used to arrive at an overall sampling variance for the entire population. The square root of this value was calculated to yield the overall standard error, which was then used to yield 95% and 99% confidence intervals for estimated total projected hires in the entire population (Table 1). In projecting loss of CHW jobs, the same process was used except that only CBOs/Clinics estimated job loss, so weighting factors were not calculated.
The confidence intervals reported are not precisely accurate, but are probably reasonably accurate. Confidence interval procedures have been developed via assumptions that are not met in these data; in particular, projected hires in the various categories are not independent of each other. The changes in the health care industry in the Bay Area are and will affect employers of different types in different ways. In addition, the samples of the individual categories are typically small, and the distribution of the number of projected hires in each category are skewed rather than normal. This probably introduces some unknown error into the interval estimates of projected hiring in each category, but less in the overall population. Finally, the respondents' hiring estimates may be biased or may turn out to be inaccurate if conditions on which they are based do not materialize (Figure 1, overview of sampling methodology, available on request).
Of the 269 organizations in the sample 76% (197) responded to the survey. One hundred twenty six (47%) reported employing no CHWs, 71 (26%) either employ CHWs or plan to hire CHWs in the next three years, 43 (16%) were duplicates or had disconnected numbers, and 29 (11%) did not respond. Of the 26% who hire CHWs, 87% (n=62) currently employ CHWs and 13% (n=9) do not currently employ CHWs but plan to hire CHWs in the next three years. From the total group of those who report currently employing CHWs and those who do not currently employ but have plans to hire in the near future, 80% project hiring CHWs (including turnover) in the next three years and 58% project creating new CHW positions in the next three years. See Table 1, (Columns I-VI) for adjusted population and hiring status by organization type.
Sixty-two respondents or 23% of our sample indicated current employment of CHWs. We analyzed these responses in depth to determine a profile of CHWs in areas of work, pay, training, education, ethnicity and gender. We also investigated which hiring factors are most important to employers and hardest to find in job applicants when hiring CHW personnel. Finally, we surveyed respondents on the barriers to the wider employment of CHWs.
A total of 504 CHWs are working in the 62 agencies reporting employing CHWs. Of these, 65% are full time and 35% are part time. County Health Departments are the biggest employers (63%), followed by CBOs/Clinics (35%). As mentioned earlier, of the 35 HMOs in the 8 counties, only one of the HMOs with a MediCal contract employs CHWs, and they report employing only two.
Forty-four percent of agencies pay full time entry level CHWs between $20,001 and $25,000 per year (Figure 3). Ninety-three percent of agencies provide health benefits for full-time CHWs. Sixty-three percent of respondents report that the CHWs within their organizations are members of a collective bargaining unit, with eighty-eight percent of the unionized CHWs being government employees. Sixty percent of agencies report that the CHW position has a career ladder or series within the CHW classification.
In looking at the funding for CHW positions, we looked at ongoing funding ("hard money") versus grants of three years or less ("soft money") coming from County/City, State, or Federal levels. Private foundation grants were also included. Fifty-five percent of CHWs are paid from ongoing "hard money" funds while 42% are on grants of three years or less. The primary funding source is City/County Funding (29%), then Federal Grants (17%), Federal Funding (15%), City/County Grants (11%), State Funding (11%), State Grants (7%), and Private Foundation Grants (7%). A few organizations (3%) completed the "Other" category indicating profits or fundraising as their funding source (Table 2).
Table 2: Funding Sources for CHW Positions
County /City Funding
"HARD MONEY" SUBTOTAL
Federal Grant (1-3 years)
County/City Grant (1-3 years)
State Grant (1-3 years)
Private Foundation Grant
"SOFT MONEY" SUBTOTAL
We found that 66% of CHWs are women. Ethnically, CHWs are very diverse, with African Americans comprising 30% of our sample, followed by Latinos (27%), White (non-Latino) (23%), Asian/Pacific Islanders (17%), and Native Americans (2%) (Figure 4).
For the majority of CHWs (58%), their formal level of education consists of a high school degree or less. Nineteen percent earned an Associate Degree and 23% possess a Baccalaureate Degree (Figure 5).
Ninety-five percent of surveyed organizations provide on-the-job-training for their CHWs. Although more formal training is provided by 80% of organizations, 62% report these trainings to be short, topical trainings as opposed to only 27% reporting a more comprehensive, competency-based training.
To identify the health topic areas in which CHWs work, respondents were asked to name the primary focus of each full-time and part-time CHW in their organization. The largest concentration of CHWs work in the area of HIV/AIDS/ STDS (27%), followed by Maternal Child Health/Perinatal (16%), Alcohol and Drug Abuse (11%) and Primary Care (10%)(Figure 6).
To determine in what areas CHWs will be working in the future, respondents were asked to identify in which health area they project an increasing number of CHWs. Eleven agencies project an increase in MCH/Perinatal, 10 in HIV/AIDS/STDS and nine in Primary Care.
In looking at what skills organizations look for in CHW applicants, we asked respondents to rate a list of skills compiled from CHW job descriptions. Respondents were then asked to rate how difficult it is to find this skill in CHW applicants. The skills reported most important to Community Health Work are multicultural competence, community outreach and communication/conflict resolution skills. The skills reported most difficult to find when hiring CHWs are group facilitation skills, self-management (job readiness), and reporting and documentation (Table 3).
Table 3: Valued Community Health Worker Skills
in Hiring Decisions
in Finding Skills
Communications and Conflict Resolution
Patient Education and Counseling
Reporting and Documentation
Knowledge of Entitlements and Referrals
4 = Not Important
= Very Hard
4 = Not Hard at All
Ninety-one percent of respondents indicate that budget constraints are a barrier to wider employment of CHWs. The other barriers to wider employment were: a lack of acceptance by other professionals (40%); difficulty in supervising employees with uneven preparation (33%); a lack of acceptance of the CHW field because of the absence of certification or other assurance of competency (32%); a lack of acceptance by clients because of a concern about "deskilling" (11%).
The CHW field is growing. The organizations surveyed estimate hiring 263 CHWs in the next three years. Forty-two percent of these hires are new positions and the rest are due to staff turnover. Projections for the entire population based on these hiring estimates indicate total projected hires of 375 CHWs (Standard Error=30.01) in the next 3 years in these eight counties. One-hundred-forty-two of these hires will be in Health Departments, 201 will be in CBOs/Clinics, 26 in National Organizations and 6 in MediCal contracted HMOs. Seventy (Standard Error=22.13) CHW positions are projected to be eliminated in the next three years. These positions are mostly grant funded (91%) and all are within CBOs/Clinics.
One fourth of the respondents to our survey report hiring CHWS. There are two reasons this is a conservative estimation of the percentage. First, because of the absence of a standard job description and job title, we had to rely on respondents to read the definition provided and correctly identify workers in their agencies as CHWs even if they are called by different names. Also, in at least two counties the number of mental health CHWs reported is low due to the fact that the Mental Health Departments contract out 60-70% of their work. Those CHWs hired by the contracting agencies are not represented in this survey because the health department does not list them as employees and the agencies are not identified as service providers that would be covered elsewhere in the survey population.
The majority (83%) of CHWs in this sample are employed by the County Health Department and by Community Based Organizations. This is in keeping with the fact that CHWs currently work primarily with the health needs of the poor, underserved, minority and high-risk populations. Health Department and CBOs are the sites where this population typically receives its health care. Furthermore, the only HMO which currently employs CHWs is the one which has the Medicaid contract. This supports the assertion that CHW are not integrated into the health delivery system as a whole but work in "poor peoples' health care" instead.
Our data show that there are growing opportunities for CHWs. In the next 3 years, the largest percentage (52%) appears to be in the public health department and the largest number of actual jobs (n=201) appears to be in the CBOs. In our sample, HMOs did not hire CHWs. We speculate that this may change as HMOs begin to sign up Medicaid managed care populations. One of the largest HMOs in the country has hired CHWs to work with its Medicaid contract patients for over two decades with positive evaluations in terms of health outcomes and cost effectiveness. 34 Further, the data on HMO and CHWs may be misleading because of the fact that HMOs may in the future subcontract to CBOs and clinics to serve their Medicaid patients. Often these CBOs and clinics have CHWs on their staff.
The Pew Health Professions Commission identified lack of secure funding as a major barrier to the expanded use of CHWs. 8,22 Our research confirms that almost half of the CHWs in our sample are being funded by grants. "Soft money" funding often means that CHW programs and jobs do not survive beyond the termination of the grant award. It is noteworthy that 55% of the CHWs were on "hard money" with most of that coming from City and County dollars.
The majority of CHWs are women (66%) of color (77%) with a high-school degree or less (58%). Most work full time as CHWs (65%), receive benefits (93%), belong to a union (63%) and have the possibility for career upward mobility within a CHW series (60%). Forty-four percent of our sample earn an annual salary of $20,00 to $25,000 with 30% making more than $25,001. Although this is not a family wage in the Bay Area, this salary is quite attractive when compared to the U.S. Department of Commerce's national data showing that women with high school degrees earn on average $11,089 per year (includes full and part-time). 35
The issues of the training and role of the CHWs as a member of the heath care team are challenging. As Pew suggests, while it is important to define the field and develop agreed-upon competencies, it is also important to note that too much "professionalization" may result in CHWs losing their effectiveness within their communities. 8
For a number of reasons, the results of this survey must be interpreted with caution when generalizing to other parts of the country. In our study we found 27% of all CHWs were working in AIDS. The Bay Area is one of the areas hardest hit by the AIDS epidemic; therefore, the ability to generalize this finding to other areas less affected by the epidemic is questionable. Also, California has one of the most diverse populations in the country and is home to many immigrants from both Asia and Mexico. For this reason, the need for CHWs may be greater in Northern California then in other, more homogeneous areas nationally. Further research needs to be conducted to see if the profile of people in CHW jobs and the roles they assume in Northern California are similar to those in other parts of the nation.
Implications for Practice
The current financial reforms in health care and the pressures on the health care delivery system to be more culturally and linguistically appropriate are providing expanded opportunities for Community Health Workers. The Pew Health Commission has made several important recommendations which need to be acted upon. They include the need to better integrate Community Health Workers into the health care delivery system, to provide federal funding to empirically document the contributions they make in the reformed health care system, to disseminate the experiences of existing CHW programs and to provide CHWs with continuing education, professional recognition and career advancement. 8,22
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fn: Emerging II Report/Emerging/ak
This report was prepared by:
Mary Beth Love, Ph.D., Co-Principal Investigator, Chair, Department of Health Education, San Francisco State University
Kristen Gardner, Research Associate
Vicki Legion, Program Director
We gratefully acknowledge the contribution of those who worked on the program in 1995 - 96:
Terry Hall, Co-Principal Investigator, Chair, Health Science Department, City College of San Francisco
Cindy Tsai, Associate Director
Vickie Quijano, Curriculum Specialist
Anna Kwong, Office Manager and producer of this report
Gloria Alonzo, Mentor
Ellen Dayton, NP, Instructor
Sholey Malawa, Consultant
Marcellina Ogbu, Dr.P.H., Instructor
Special acknowledgment to Yvonne Lacey and Eva Torres, founding
Our gratitude to leaders of City College of San Francisco and San Francisco State University whose support makes our work possible:
Dean Natalie Berg, Director Robert Gabriner and Provost Frances Lee (CCSF) and Dr. Paul Fonteyn, Assoc.Vice President, Dean Don Zingale, Interim Assoc. Dean Amy Hittner (SFSU).
Our thanks to all those who responded to the survey that resulted in this
Adjunct Faculty 1996-97
Len Finocchio, Associate Director, Pew Health Professions Commission, University of California at San Francisco
George R. Flores, M.D., MPH, President, California Conference of Local Health Officers
Marcellina Ogbu, Dr.P.H., Health Educator, San Francisco Dept. of Health
Robert W. Prentice, Ph.D., Deputy Director of Health for Community Public Health Services
The Appendix contains "CHWs: Integral Members of the Health Care Workforce," by Anne Witmer et.al, from the American Journal of Public Health 1995.
The Community Health Worker Training Program is funded in part by the Fund for the Improvement of Post Secondary Education (FIPSE) U.S. Department of Education, the Carl D. Perkins Vocational and Applied Technology Education Act 1990, the Bernard Osher Foundation, and the Chancellor's Office of the California Community College System.
Note: As this edition of this report is intended for a community and professional audience, not a research audience, the extended discussion of research methods will appear as a footnote. Pie charts have been included for easy reading; numerical charts are also available on request.
(c) Accepted for publication in Health Education Quarterly