Community Health Worker / Promotor(a) Resources

For further information on promotoras/es and community health workers training and certification program in Texas, go to the Texas Department of State Health Services Community Health Worker or Promotor(a) Training and Certification Program webpage.

The Medical and Research Librarians have selected this list of journal articles and/or reports in the Promotor(a) or Community Health Worker Training and Certification Program. 

A review of community health worker integration in health departments. Ignoffo S, Gu S, Ellyin A, Benjamins MR. J Community Health. Published online October 12, 2023. doi:10.1007/s10900-023-01286-6
Abstract
Community health workers (CHWs) are frontline public health workers who bridge the gap between historically marginalized communities, healthcare, and social services. Increasingly, states are developing the CHW workforce by implementing training and certification policies. Health departments (HDs) are primarily responsible for community health through policy implementation and provision of public health services. The two objectives of this study are to explore: (1) state progress in establishing CHW training and certification policies, and (2) integration of CHWs in HD workforces. In this scoping review, we searched PubMed, CINAHL, and Google Scholar for articles published between 2012 and 2022. We looked for articles that discussed state-level certification and training for CHWs and those covering CHWs working with and for city, county, state, and federal HDs. We excluded studies set outside of the US or published in a language other than English. Twenty-nine studies were included for review, documenting CHWs working at all levels of HDs. Within the included studies, HDs often partner with organizations that employ CHWs. With HD-sponsored programs, CHWs increased preventative care, decreased healthcare costs, and decreased disease risk in their communities. Almost all states have begun developing CHW training and certification policies and are at various points in the implementation. HD-sponsored CHW programs improved the health of marginalized communities, whether CHWs were employed directly by HDs or by a partner organization. The success of HD-sponsored CHW programs and state efforts around CHW training and certification should encourage increased investment in CHW workforce development within public health.

Health care impacts of resource navigation for health-related social needs in the accountable health communities model. Parish W, Beil H, He F, et al. Health Affairs. 2023;42(6):822-831. Published 2023 May 17. doi.org/10.1377/hlthaff.2022.01502
Abstract
Social determinants of health can adversely affect health and therefore lead to poor health care outcomes. When it launched in 2017, the Accountable Health Communities (AHC) Model was at the forefront of US health policy initiatives seeking to address social determinants of health. The AHC Model, sponsored by the Centers for Medicare and Medicaid Services, screened Medicare and Medicaid beneficiaries for health-related social needs and offered eligible beneficiaries assistance in connecting with community services. This study used data from the period 2015–21 to test whether the model had impacts on health care spending and use. Findings show statistically significant reductions in emergency department visits for both Medicaid and fee-for-service Medicare beneficiaries. Impacts on other outcomes were not statistically significant, but low statistical power may have limited our ability to detect model effects. Interviews with AHC Model participants who were offered navigation services to help them find community-based resources suggested that navigation services could have directly affected the way in which beneficiaries engage with the health care system, leading them to be more proactive in seeking appropriate care. Collectively, findings provide mixed evidence that engaging with beneficiaries who have health-related social needs can affect health care outcomes.

Community health worker integration with and effectiveness in health care and public health in the United States. Knowles M, Crowley AP, Vasan A, Kangovi S. Annu Rev Public Health. 2023;44:363-381. Published 2023 Apr 3. doi:10.1146/annurev-publhealth-071521-031648
Abstract
Community health workers (CHWs) have worked in a variety of settings in the United States for more than 70 years and are increasingly recognized as an essential health workforce. CHWs share life experience with the people they serve and have firsthand knowledge of the causes and impacts of health inequity. They provide a critical link between marginalized communities and health care and public health services. Several studies have demonstrated that CHWs can improve the management of chronic conditions, increase access to preventive care, improve patients' experience of care, and reduce health care costs. CHWs can also advance health equity by addressing social needs and advocating for systems and policy change. This review provides a history of CHW integration with health care in the United States; describes evidence of the impact of CHW programs on population health, experience, costs of care, and health equity; and identifies considerations for CHW program expansion.

Impact of delivering a healthy lifestyle intervention: promotora findings from Familias Sanas y Activas II. Madanat H, Martinez A, Molina M, Ayala GX. J Health Sci Educ. 2023;1(3):1-7. Published 2023 Jan.
Abstract
Background: Community health workers, promotoras, have been identified as effective change agents of their community members' health behaviors and health status. However, few studies have examined the effects of delivering an intervention on the promotoras themselves.
Objectives: This study assessed whether promotoras delivering a healthy lifestyle intervention for adults improved their health behaviors and health status from baseline to 6- and 12-months post-baseline.
Methods: Volunteer promotoras were trained to promote healthy lifestyles including physical activity through workshops and free group exercise classes throughout their communities. Twenty completed all required trainings and delivered at least one class during the period between baseline and 12-month assessments. The promotoras were measured on the following variables: Systolic and diastolic blood pressure, waist circumference, weight, and height. Additionally, they reported their health behaviors and status including moderate-to-vigorous physical activity, beverage consumption, sleep duration, and depressive symptoms.
Results: Repeated measures ANOVAs showed statistically significant decreases from baseline to 6 months for systolic blood pressure (p ≤ 0.05), diastolic blood pressure (p ≤ 0.001) and body mass index (p ≤ 0.05). Changes in self-reported measures were not statistically significant although trends were observed with increases in water consumption.
Conclusions: Findings from this study suggest positive effects associated with delivery of a PA intervention. This is one of the first studies to focus on a cohort of promotoras to examine health outcomes from delivering a healthy lifestyle intervention. It is important to further explore these impacts on the community health workers as they have become increasingly essential to the health of some communities.

Care management for patients with type 2 diabetes: the roles of nurses, pharmacists, and social workers. Bodenheimer TS & Willard-Grace R. Health Affairs. 2022;41(7):947-954. Published 2022 June 27. doi.org/10.1377/hlthaff.2022.00227
Abstract
Managing patients with type 2 diabetes takes time. Clinicians in primary care, where most diabetes visits take place, lack that time. Planned visits by diabetes care managers - nurses, pharmacists, social workers, and other team members - assist clinicians and are associated with improved glycemic control. Particularly effective is care management featuring nurses or pharmacists adjusting medications without prior physician approval. Care management programs need to pay close attention to inequities in diabetes care and outcomes. The widespread implementation of diabetes care management in primary care faces several barriers: lack of an adequate, diverse, trained care manager workforce; regulations limiting care managers’ scope of practice; and financial models not supportive of care management. Wide-ranging policies are needed to address these barriers. In particular, payment reform is needed to stimulate the spread of diabetes care management: adding fee-for-service codes that adequately pay care managers for their work, adopting shared savings models that channel savings back to primary care, and increasing the percentage of health care spending dedicated to primary care. In this article we explore key questions around type 2 diabetes care management, review the published evidence, examine the barriers to its wider use, and describe policy solutions.

Impact of community health workers on access to care for rural populations in the United States: a systematic review. Berini CR, Bonilha HS, Simpson AN. J Community Health. 2022;47(3):539-553. Published 2022 Jun. doi:10.1007/s10900-021-01052-6
Abstract
Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women's health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

Community health worker sustainability: funding, payment, and reimbursement laws in the United States. Schmit CD, Washburn DJ, LaFleur M, Martinez D, Thompson E, Callaghan T. Public Health Rep. 2022;137(3):597-603. Published 2022 May-Jun.
doi:10.1177/00333549211006072
The number of community health workers (CHWs) in the United States is expected to increase 13% in the next decade (from 127,100 to 144,100 by 2029). CHWs function as patient navigators, health promoters, health educators, patient advocates, and outreach workers or find employment or volunteer work in various other positions. In these capacities, CHWs are frontline health workers who connect people with needed health and social services in their communities and address the social determinants of health and inequities experienced by their clients.

Community health worker impact on knowledge, antenatal care, and birth outcomes: a systematic review. Scharff D, Enard KR, Tao D, Strand G, Yakubu R, Cope V. Matern Child Health J. 2022;26(1):79-101. Published 2022 Jan. 
doi:10.1007/s10995-021-03299-w
Abstract
Objectives: Community health worker (CHW) interventions have been shown to be effective in areas of maternal and child health (MCH), mostly in relation to infant and neonatal mortality. The specific aims of this review were to expand outcomes to include improving knowledge related to pregnancy and infant health and the receipt of antenatal care (ANC), along with birth outcomes. We also summarized the role, characteristics and activities of CHWs in interventions conducted in settings with demonstrated improvements in key MCH outcomes.
Methods: Articles were retrieved from: PubMed, CINAHL, Global Health, Scopus, Web of Science, and the Cochrane Library from January 2008 through 2018. We included evaluation studies that utilized CHWs as all or part of an intervention to improve outcomes, were printed in English, and published in peer-reviewed journals.
Results: Initial electronic database search identified 816 studies and 123 studies met inclusion criteria for full text review. The quality assessment resulted in 0 strong-, 19 moderate-, and 25 weak-rated studies. In most interventions, CHWs were a component of a larger intervention. The majority of the studies (n = 10) found that a CHW intervention can have a positive impact on outcomes. CHW interventions showed improvements in knowledge and ANC. When combined with clinical services, the interventions positively impacted birth outcomes. Most conducted home visits and utilized CHW that were members of the community.
Conclusions for practice: CHWs serve an important role as health educators conducting home visits as a member of the community they serve. They should also continue to collaborate with clinical providers to address MCH outcomes.

Processes for implementing community health worker workforce development initiatives. Barbero C, Mason T, Rush C, et al. Front Public Health. 2021;9:659017. Published 2021 Jun 24. doi:10.3389/fpubh.2021.659017
Abstract
Introduction: The objective of this observational, cross-sectional study was to identify, document, and assess the progress made to date in implementing various processes involved in statewide community health worker (CHW) workforce development initiatives. 
Methods: From September 2017 to December 2020, we developed and applied a conceptual model of processes involved in implementing statewide CHW initiatives. One or more outputs were identified for each model process and assessed across the 50 states, D.C., and Puerto Rico using peer-reviewed and gray literature available as of September 2020. 
Results: Twelve statewide CHW workforce development processes were identified, and 21 outputs were assessed. We found an average of eight processes implemented per state, with seven states implementing all 12 processes. As of September 2020, 45 states had a multi-stakeholder CHW coalition and 31 states had a statewide CHW organization. In 20 states CHWs were included in Medicaid Managed Care Organizations or Health Plans. We found routine monitoring of statewide CHW employment in six states. 
Discussion: Stakeholders have advanced statewide CHW workforce development initiatives using the processes reflected in our conceptual model. Our results could help to inform future CHW initiative design, measurement, monitoring, and evaluation efforts, especially at the state level.

Community health worker leadership in Louisiana, during and after Hurricane Katrina. Haywood CG, Feist DR, Sugarman MK, Ezouah P, Wennerstrom A. Am J Public Health. 2020;110(10):1498-1499. Published 2020 Oct. doi:10.2105/AJPH.2020.305741
Community health workers (CHWs) have been building capacity among under-resourced populations in the United States for decades by addressing health inequity and its underlying social determinants. In 2005, hurricanes Katrina and Rita struck the Greater New Orleans, Louisiana area, bringing massive infrastructure damage and loss of life. A complex series of political and social issues followed, leaving close to half of the city’s residents displaced a year later. Those who returned struggled to rebuild their homes, enroll their children in a newly privatized school system, live in increasingly gentrified neighborhoods, navigate a fragmented health care system, and grieve the loss of entire communities. CHWs not only supported recovery from the devastation but also learned important lessons through organizing themselves into a professional association to support their growing workforce and influence policy.

Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Kangovi S, Mitra N, Grande D, et al. 
Health Affairs. 2020;39(2):207-213. Published 2020 Feb. 
doi.org/10.1377/hlthaff.2019.00981
Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

Physical activity change after a promotora-led intervention in low-income Mexican American women residing in South Texas. Salinas JJ, Parra-Medina D. BMC Public Health. 2019;19(1):782. Published 2019 Jun 20. doi:10.1186/s12889-019-7105-6
Abstract
Background: The purpose of this study was to determine physical activity (PA) preferences associated with increases in moderate-to-vigorous physical activity (MVPA) and decrease in sedentary time in Mexican American (MA) women participating in a Promotora (community health worker)-led intervention on the U.S.-Mexico border.
Methods: Enlace ('to link' in Spanish) was a randomized clinical trial to increase PA in low-income, MA women living in South Texas on the U.S.-Mexico border. A total of 620 participants were recruited into the study. The primary outcome was increase in moderate to vigorous physical activity (MVPA) using the Actigraph GT3X 16 Mb accelerometer. A modified version of the Community Health Activities Model Program for Seniors Physical Activity (CHAMPS) instrument was used to predict MVPA. Adjusted and unadjusted logistic regression models predicted change in MVPA by change in CHAMPS activities. ANOVA analysis determined the variance explained in change in MVPA by change in time engaged in activity. Individual effect sizes were then calculated for significant activity type change on MVPA increase.
Results: There were significant increases in all CHAMPS activities except aerobic machines and errand walking. An increase in leisure walking (O.R. = 2.76, p = .046), errand (O.R. = 3.53, p = .051), and brisk walking (O.R. = 4.74, p = .011), dance (O.R. = 8.22, p = .003), aerobics class (O.R. = 32.7, p = .001), and light housework (O.R. = 6.75, p = .000), were associated with a decrease in sedentary time. Significant effect sizes for MVPA were observed for jogging (1.2, p = .050), general exercise (1.6, p = .024), and other exercise not specified (2.6, p = .003). Significant effect sizes for sedentary time were detected for leisure time (.031, p = .036), errands (.017, p = .022), brisk walking (.022, p = .003), dance (.042, p = .005), and aerobics class (.013, p = .009).
Discussion: Participants who engaged in walking and aerobic activities through this intervention significantly increased their engagement in MVPA and decreased their sedentary time. These findings are novel, since preferences have not been examined in relation to MVPA or sedentary time in MA women.
Conclusion: PA preferences need to be considered when aiming to promote activities that reduce sedentary time and increase PA participation among marginalized groups, such as MA women.

Educating Hispanic women about cervical cancer prevention: feasibility of a promotora-led charla intervention in a farmworker community. Fleming K, Simmons VN, Christy SM, et al. Ethn Dis. 2018;28(3):169-176. Published 2018 Jul 12. 
pmcid:PMC6051510
Hispanic women suffer disproportionately from cervical cancer incidence and mortality compared with non-Hispanic Whites in the United States. Peer-led health education and coaching via charlas (talking circles) may improve cervical cancer screening and early detection rates among specific sub-groups such as farmworker communities. This pilot study sought to collect preliminary evaluation data about the feasibility of implementing a promotora-led cervical cancer education intervention among women from a farmworker community. The study took place between April 2014 and November 2014. Created based on an established network (Tampa Bay Community Cancer Network, TBCCN), in partnership with a local farmworker organization (Farmworkers Self-Help, Inc.), the project entailed refinement of a curriculum guide including Spanish-language educational resources (teaching cards). Social Cognitive Theory and the Health Belief Model provided the conceptual framework for the study. Six women from the farmworker community helped to refine the intervention and were trained as promotoras. They successfully delivered the program via charlas to a total of 60 participants who completed baseline and post-intervention measures on knowledge (cervical cancer/HPV), beliefs, self-efficacy, and intentions. Findings demonstrated gains in knowledge and self-efficacy among charla participants (P<.0001), and support the promise of a community-driven intervention that is delivered by promotoras who use their cultural knowledge and trustworthiness to educate women about cancer screening practices. Results also add to the literature on the use of a charla approach for cancer prevention education within a farmworker community to prompt discussions about health. Future research should evaluate peer-led programs on a larger scale and among other at-risk groups in other community settings.

ANDALE Pittsburgh: results of a promotora-led, home-based intervention to promote a healthy weight in Latino preschool children. Taverno Ross SE, Barone Gibbs B, Documet PI, Pate RR. BMC Public Health. 2018;18(1):360. Published 2018 Mar 16. doi:10.1186/s12889-018-5266-3
Abstract
Background: Latino preschool children have higher rates of obesity than preschool children from other racial/ethnic groups; however, few effective, culturally appropriate interventions exist targeting this group. The purpose of this study was to test the feasibility of a 10-week, promotora-mediated, home-based intervention to promote a healthy weight in Latino preschool children.
Methods: Trained promotoras (community health workers) delivered 10, 90-min weekly interactive and tailored sessions to Latino families living in Allegheny County. Participants were recruited through promotoras' own social networks and community gatherings, flyers, and word of mouth. Primary outcome measures included child body mass index (BMI) z-score and percentile. Secondary outcome measures included child objectively measured physical activity and dietary intake, and the home social and physical environment (e.g., parent health behaviors, parent self-efficacy, parental support, physical activity equipment in the home). The final analysis sample included 49 of 51 participants who completed both baseline and follow-up assessments.
Results: Participants included mothers (33.5 ± 6.1 years old) and their preschool-aged children who were primarily 1st generation immigrants from Mexico (65%). The primary analyses of BMI percentile and z-score showed no change post-intervention. However, there was a significant decrease in child BMI percentile for overweight and obese children from baseline to follow-up (p < .05). We also saw significant pre/post increases in child daily fruit and vegetable intake, and parent moderate-to-vigorous physical activity, fruit and vegetable servings per day, and self-efficacy; and significant decreases in child saturated fat and added-sugar intake, and child and parent screen time (p's < .05)
Conclusions: Despite the short duration of the intervention and follow-up, this pilot study showed promising effects of a promotora-mediated intervention to promote a healthy weight in Latino preschool children.

The Medical and Research Librarians have selected these resources on the Promotor(a) or Community Health Worker.

CDC Resources for Promotores de Salud/Community Health Workers
Promotores de salud, also known as promotoras, is the Spanish term for “community health workers”. The Hispanic community recognizes promotores de salud as lay health workers who work in Spanish-speaking communities. The CDC has compiled helpful information for promotoras. 

Community Health Worker (CHW) Resources
These resources are collected from programs across the Centers for Disease Control and Prevention (CDC) that host materials pertinent to CHWs. These resources should be helpful not only to CHWs, but also to those who work with them. 

Diffusion of Community Health Workers within Medicaid Managed Care: A Strategy to Address Social Determinants of Health. Carolina Nkouaga, Arthur Kaufman, Charlie Alfero, and Claudia Medina, Health Affairs Blog. 

Heart Disease and Stroke Prevention: Interventions Engaging Community Health Workers. The Community Guide, March 2015.

Map on Community Health Worker Models, Dec. 2021, National Academy of State Health Policy.
This NASHP map and chart makes it easy for you to find information about various activities related to CHWs in the states. 

National Rural Health Association (NRHA) provides information on:

• Border Health Initiative

• Rural Community Health Initiative

• Policy Papers like Community Health Workers: Recommendations for Bridging Healthcare Gaps in Rural America

• Rural Community Health Worker Training

State Approaches to Community Health Worker Certification (June 2022).
Each state that has developed a CHW certification program, however, has taken its own approach to setting requirements for certification and determining how to administer the program.

State Community Health Worker Policies
Information was collected through a combination of state surveys and NASHP staff research. It offers a snapshot of how states are defining, training, certifying, and paying for the CHW workforce — as well as how states are developing cross-agency and state-to-local strategies to improve community health in partnership with CHWs. This is a dynamic policy space, and many states are continuing to develop new approaches.