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Developing a Research Agenda for Cultural Competence in Health Care:
Community Health Workers
Draft research agenda--version 1.0

Resources for Cross Cultural Health Care
and the U.S. Department of Health and Human Services
Office of Minority Health and the Agency for Healthcare Research and Quality

We invite public input on our draft research agendas. Please read the following document and send your comments to rcchc@aol.com. We are especially looking for recommendations for additional research questions and methodological/policy considerations. We are also seeking additional bibliographic references for the literature review abstracts. Comments received by December 10 will be incorporated into the final report–comments will also be posted online.

Definition

Community health workers (CHWs) are typically members of a particular community whose task it assist in improving the health of that community in cooperation with the health care system or public health agencies.

The literature suggests that community health workers can work as agents of change by providing a variety of services including; outreach to underserved and hard to reach populations, health promotion/disease prevention educational instruction, patient tracking, needs assessment and the provision of follow-up services, patient advocacy and assistance, and in some instances limited health care services.

Although many of these services are capable of being delivered through a direct systems-based approach, CHWs are often trained to provide these same services integrating a more culturally and linguistically sensitive approach. In addition to being part of the existing community and social network, CHWs ideally possess certain skills and capacities that are essential to gaining the trust and acceptance individuals. These may include cultural communication and mediation skills, an understanding of the community’s health belief systems and knowledge of a community’s strengths and capacities, and the ability to use effective approaches for reaching targeted individuals. Through an integrated approach, CHWs can facilitate a better understanding of the changes that are sought without threatening the interests or cultural values of the community.

In addition to influencing health-related behavioral change and outcomes in targeted communities, CHWs can also assist systems and service providers by soliciting information regarding community barriers, patterns of social interaction and decision making, past efforts aimed at changing health behaviors, and associated successes and failures. This information will enable providers and institutions to adopt methods more in accordance with the targeted community.

Synthesis Of Findings From Current Literature

Descriptive

There is sufficient literature that examines or describes the use of community health workers or lay health advisors, content and structure of CHW assisted programs and the methodologies by which CHWs were integrated into specific programs as part of a corrective strategy to supplement or modify existing initiatives. The literature highlights variations in training and preparation, roles and responsibilities, and the controversy associated with using CHWs. This literature can provide the foundation for further meta-analysis detailing the utility of CHWs, core competencies, associated data collection, institutional and structural barriers to using CHWs and potential models for duplication. This base can be used to identify those cultural components that make the work of CHWs more effective in meeting community-based needs.

Empirical research

Literature that empirically measures the impact of CHWs is limited. Surveys conducted by different institutions validate this finding for both published and non-published sources. Studies that attempted to quantify the impact of CHWs on various outcomes looked at the effect of CHWs on patient satisfaction, knowledge, service utilization, and health status. No studies were identified that examined the cost effectiveness or cost benefits of using CHWs.

Findings suggest:

• CHWs were effective in increasing health-related knowledge and self-care practices through educational instruction. They were also credited with higher rates of health promotion course completion.
• CHWs facilitated behavioral change in the target population by providing encouragement, support and serving as role models. Increases in screening rates were attributed directly to their use in several studies.
• CHWs were effective in decreasing high-risk behaviors in the target population.
• Enhanced case management tracking and monitoring of patients by CHWs resulted in better follow-up with medical care.
• The use of CHWs was highly valued by administrators, program staff and clients.

Literature Search Terms

Community health worker, community health advocate, neighborhood worker, indigenous health worker, lay health adviser/worker, consejera, promotora, outreach workers, outreach, liaison

Key Research Questions

What are the effective uses of community health workers? The RAC suggested that there is a need to conduct a meta-analysis to identify models that have documented success in achieving improvements in outcomes. This analysis should include an examination of the specific roles and responsibilities of CHWs, interventions delivered by CHWs, strategies for partnerships, issues related to the use of credentialed versus non-credentialed CHWs, the identification of indicators or standards for success and a determination of the most effective use of CHWs. The RAC also suggested that this analysis should be broadened to include an examination of international models.

Both the literature and RAC highlighted the need for additional research that evaluates the utility of CHWs and their subsequent impact on health outcomes. Additional process evaluation questions to be considered include: What proportion of the targeted population is successfully reached by CHWs? Do variations exist in levels of successful outreach when using CHWs as an intervention versus other methods of outreach (i.e. case management)? What institutional barriers prevent the use of lay health workers? Cost benefit studies should examine questions related to the use of CHWs as a cost effective alternative to other comparable interventions and whether it is appropriate to use cost as a measure of success? An examination of the value of CHWs from the stakeholders perspective need to be considered.

More scientific evidence linking CHWs directly to health outcomes is needed. Future studies should examine the use of CHWs versus no intervention, and subsequent impacts on health outcomes. Outcome questions that need to be examined include: What components of the CHW’s role impact behavioral change? Of these changes, which can be linked to improvements in utilization and health outcomes? However, the RAC noted that the expectation of linking CHWs to health outcomes may be unrealistic and further consideration should be given to assessing the added value of CHWs to programs rather than quantifying success in terms of positive impacts on health outcomes.  

Methodological Concerns

The RAC highlighted methodological concerns that could impact future research efforts. These include:

• The inability to standardize relationships between CHWs and their clients. The literature describes CHWs as having a very dedicated advocacy role and individualized approach that differs from worker to worker. The relationships CHWs form with individuals in the target population canot be individually standardized whereby weakening experimentally controlled designs.
• Data collection is not standardized and often more qualitative in nature thereby preventing any comparative analysis.
• Length of study, compounded by a lack of personnel and financial resources, will be barriers to conducting health outcomes research or any ongoing monitoring of behavioral changes.
• Difficulties reaching populations, high attrition and the mobility of populations compound difficulties in long-term studies.
• Ambiguous definition of "community". Often systems make the mistake of assuming that a community is aggregation of individuals of a similar race, ethnicity, language or geographic locale, and do not take into consideration social component or the organizational structure that links individuals to a specific community.

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