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Community Health Worker (CHW):
A New Profession in the Health Care
Workforce?
Bita A. Kash, MBA, FACHE
Marlynn L. May, PhD, MDiv
Ming Tai-Seale, PhD, MPH
Southwest Rural Health Research Center
School of Rural Public Health, Texas A&M University Health Science Center
TAMU 1266
College Station, Texas 77843-1266
(979) 458-0653
www.srph.tamushsc.edu/srhrc
Project Support - Acknowledgement
 Projects
funded by a grant (5-UICRH00033) 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 Objective
1. To apply economic perspective of
market failure (Arrow, 1963), and
human capital theory (Becker, 1962) to
study the history and development of
certification programs for CHWs in the
United States.
2. To explore potential workforce
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).
Background
Why 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. States are moving towards standardization
of training and certification of CHWs in
order to increase and improve CHW
utilization and income potential.
2. CHWs are an emerging new class of
professionals in the healthcare workforce
market, and therefore will experience an
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
Selection Criteria
In-depth
Interviews
19 States
Atlas.ti
Typology
of CHW
Programs
Summary of Results
• 19 states have existing CHW certification and/or
training programs.
• Most of these states have training programs at
community colleges and direct service agencies.
• Only 9 of these programs are supported by the
state either financially or through other means.
• AK, and TX are the only states administering a
certification program for CHWs.
Summary of Results
• AZ, CA, NM, KY, and MA are considering state-level
certification for CHWs.
•
OH, NC, and NV have established standards for training
of CHWs at the state level, but do not administer
certification programs.
•
Agency level training appears to be most prevalent in
“special case” states that utilize specialized lay health
workers in areas such as prenatal care, heart disease,
cancer, mental health, and AIDS prevention.
Level of Support for
CHW Programs
OR
OH
IN WV
VA
KY
NC
NV
CA
AZ
MA
CT
MD
NM
AK
TX
MS
FL
HI
State Legislated/Required
by State
Supported by State
No State Support/Agency
Based
Typology of CHW Programs
State
Legislated or
Required
Supported
by State
(financial or
other)
Not
Supported
by State
Certification
Training
Special
Cases
AK, TX
OH, NC,
NV
IN
AZ, CA,
HI, KY,
MA, NM,
VA
OR
CT, FL
MS, MD,
WV
Conclusions:
Emergence of CHW Programs
Initiatives can be described as society
taking steps to correct dissatisfaction
with the competitive equilibrium achieved
in the market (Arrow, 1963).
All programs reported a common theme in
the history of their programs, and the
initial creation of the CHW occupation:
unmet need and lack of access to healthcare
services in culturally, economically and
geographically difficult to reach communities.
Conclusions:
Goals and Impact of Programs
Three prevalent themes on training and certification:
• Schooling at the community college level:
provides career advancement opportunities into
nursing and social work.
• On-the-job training at the agency level:
improves standards of care, outcomes, secures
CHW income, and improves retention of CHWs.
• Certification at the state level: recognizes the
value of CHWs, enhances reimburseability of
CHWs, and improves self-esteem and self worth
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
advancement of CHWs by subsidizing
education (community college approach).

Provide stable jobs and incomes for CHWs by
supporting the reimbursement of trained and
certified CHWs (on-the-job training and state
certification approach).
Depending on what a state department of health
or federal health agency attempts to achieve in
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 1266
College Station, Texas 77843-1266
(979) 458-0653
www.srph.tamushsc.edu/srhrc