Through advocacy, outreach, and clinical services, community health workers (CHWs) are playing an increasingly important role in enhancing the capacity of the American health care system. With appropriate training and a broader recognition of their potential, CHWs can play a complementary role in helping their communities deal with natural disasters and environmental emergencies. In promoting community health and facilitating disaster preparedness, response, and recovery, CHWs can significantly increase the resilience of communities in anticipation of future disasters.
As part of the Gulf Region Health Outreach Program (GRHOP) and the Consortium for Resilient Gulf Communities (CRGC), the University of South Alabama's Coastal Resource and Resiliency Center (USA-CRRC) has developed and implemented a training curriculum designed to better prepare CHWs to enhance public health and contribute to community resilience. In addition to basic training modules, the curriculum includes disaster-related components aimed at mitigating risks, minimizing impacts, and speeding the process of community recovery. This article provides insights into the primary issues associated with the initial development of such training and shares lessons learned regarding needed knowledge and skills.
Given their standing in the communities served, CHWs have great potential to increase community resilience by promoting overall community health, as well as improving disaster response and recovery, but the realization of this potential will require adjustments in basic training curricula, as well as the addition of supplemental training topics. In addition, it is important that emergency management officials recognize the utility of CHWs in this area and facilitate their inclusion in disaster response and recovery.
Community Health Worker Overview
The ideal CHW is a trusted community member who understands community norms and needs and is fluent in the language and culture of the people served.1–4 CHWs are typically trained to promote healthy lifestyles, to improve health literacy, to perform basic clinical duties, and to identify and publicize relevant resources. As frontline public health workers, some are employed in health care organizations such as hospitals, hospices, and health clinics, whereas others operate outside the health care system in community-based or faith-based organizations. Depending on where they work, CHWs may be involved in facilitating greater access to health care services, improving patient compliance with clinical directives, serving as intermediaries between patients and professionals, offering assistance with health and social service resources, providing informal counseling, and conducting educational and outreach activities.4–6 While “community health worker” is the label most commonly used and is endorsed by the American Public Health Association,3 CHWs are sometimes referred to as lay health advisors, peer health advocates, health auxiliaries, Promotoras de Salud (health promoters), health educators, and patient navigators.
While results have been mixed, academic research has largely confirmed the effectiveness of CHWs as a means of increasing primary and behavioral health care access7 and lowering the overall cost of care for those served through lifestyle changes and preventive medicine.8 Effectiveness may vary by disease or condition, but evaluations of CHW programs have generally shown positive impacts on individuals' health behaviors and outcomes in a wide variety of areas and populations.9–15 In addition, research has demonstrated that CHW interventions targeting underserved and marginalized populations in a culturally sensitive and community-based approach can effectively promote healthy behaviors and make a positive contribution to reducing socioeconomic disparities in the morbidity and mortality associated with chronic diseases and other health conditions.8,16–18
An appreciation of the utility of CHWs in pursuing public health objectives is evidenced in the Patient Protection and Affordable Care Act directive that the Centers for Disease Control and Prevention facilitate the use of CHWs “to promote positive health behaviors and outcomes for populations in medically underserved communities.”19(p124) Furthermore, a recent article in The New England Journal of Medicine sums up the situation by noting that “scaling up the community health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs.”20(p894)
Given the demonstrated utility and effectiveness of CHWs in the health care arena, it has been suggested that they could also play critical roles in disaster preparedness, response, and recovery efforts.6,21–24 The combination of basic CHW activities in health care settings and the potential role in disaster management can significantly increase community resilience. In this context, community resilience is defined as the capacity of a community to overcome vulnerabilities and develop capabilities that help it withstand and mitigate the impact of a disaster, regain community self-sufficiency, and recover, at a minimum, to predisaster levels of health and well-being.25 Basic training of CHWs will prepare them to increase resilience by promoting overall community health. To maximize their potential in emergency situations, CHWs must undergo appropriate supplemental training.
As part of the GRHOP, the Deepwater Horizon (DWH) Medical Settlement funds the Community Health Worker Training Project (CHWTP). This project is housed in USA-CRRC and is charged with developing and implementing a training curriculum to prepare CHWs to improve health outcomes and enhance disaster resilience in target communities along the northern Gulf Coast. Subsequently, USA-CRRC became part of CRGC, funded by the Gulf of Mexico Research Initiative. With goals similar to CHWTP, the consortium provided additional funding for the training and placement of CHWs in areas affected by the DWH oil spill. As of this writing, USA-CRRC has trained 90 CHWs, many of whom are currently using their knowledge and skills in pursuit of programmatic objectives to enhance community disaster resilience among target populations along the northern Gulf Coast.
Current CHW Training Curricula
Core competencies for CHWs vary widely across the United States.5,26 This not only is due, in part, to the varied roles of CHWs but also reflects the lack of any national-level certification or licensing procedure, which allows states that provide for CHW certification to establish their own sets of competencies. A recent project undertaken by the University of Texas School of Public Health aggregated and summarized core competency skills requirements prevailing in 6 of the states that certify CHWs (California, Massachusetts, Minnesota, New York, Oregon, and Texas).27 These skills include (1) communication skills; (2) interpersonal and relationship-building skills; (3) service coordination and navigation skills; (4) capacity-building skills; (5) advocacy skills; (6) education and facilitation skills; (7) individual and community assessment skills; (8) outreach skills; (9) professional skills and conduct; (10) evaluation and research skills; and (11) knowledge base.
This list is useful for conceptualizing the competencies needed to work effectively as a CHW, but it does not provide the level of specificity needed to develop a comprehensive training curriculum. While a degree of consistency across curricula might be considered appropriate, there appears to be little movement in that direction. Indeed, it might be counterproductive to impose a standard curriculum in an attempt to professionalize an occupation that is designed to be nonprofessional.5 In addition, standardization of training could limit the capacity of both health care providers and community-based organizations to best meet the needs and preferences of their service populations. As a result, training approaches tend to reflect a patchwork of courses developed by academic institutions, community-based organizations, and for-profit companies, combined with on-the-job training.28 While a comprehensive survey of CHW training curricula is beyond the scope of this article, there are numerous examples available for review on the Internet.*
On the basis of these considerations, USA-CRRC had significant guidance but wide latitude in developing its training curriculum. In undertaking the task of creating basic training modules for CHWs, USA-CRRC subcontracted with one of the GRHOP partners, the Environmental Health Capacity and Literacy Project at Tulane University. In addition, each of the 5 GRHOP partner programs were tasked with developing and delivering specialty training modules based on their relevant expertise. The initial training curriculum included basic and specialty modules as presented in the Table.
These modules were designed to be delivered in 72-hour residential training sessions conducted over a 2-week period at commercial hotels. Classes were conducted from 9 AM to 4:30 PM, with an hour break for lunch. Most of the modules were delivered in either the 3-hour morning session or the 3½-hour afternoon session. Between June 2013 and August 2016, USA-CRRC conducted 4 of these CHW training sessions. Participants were recruited from southeastern Louisiana, the coastal counties of Mississippi and Alabama, and the Florida panhandle, and a total of 90 CHWs were trained.
Maximizing the Effectiveness of CHW Training
Over the course of the 4 training sessions, the original curriculum underwent significant revision in an effort to maximize its effectiveness in preparing CHWs to work in the areas of disaster preparation, response, and recovery. In the early stages, modules on chronic disease and women's health issues were added and the research module was deleted. Motivational interviewing was shortened and folded into the interventions module, and the disaster preparedness module was expanded to include more about mitigation, response, and recovery. Subsequently, additional areas for adjustments and expansion have been identified on the basis of evaluations of training effectiveness, further elaboration of conceptual expectations, and investigation of comparable curricula; these are presented in the following text.
In evaluating the effectiveness of the training, there are a number of factors to consider. In the first place, trainees must accept the training curriculum and delivery as valid and appropriate. During the training sessions, participants regularly completed evaluation forms that included ratings of facilities, training materials, individual presentations, pedagogical approaches, and overall effectiveness. Generally, participants were very positive about their training experience. At each training session, participants were asked to “rate the overall effectiveness of your training on a scale from 1 to 5, with 1 being the lowest and 5 the highest.” Among the total 90 CHW trainees, effectiveness ratings were very high, with 86% rating it 5 and 12% rating it 4 (2% did not answer).
Trainees were also encouraged to offer comments regarding their training experiences. Their feedback on teaching approaches and evaluations of individual modules provided useful guidance in adjusting the training approach. General lessons learned from a review of the ratings and comments include the following:
- It is important not to attempt to cover too much material per training topic; participants may be overwhelmed.
- Highly technical scientific concepts, theories, and statistics are not appropriate for CHW training; this is especially the case in the areas of environmental toxicity, risk assessment, and health care research.
- Avoid overly technical language and jargon; research scientists may not be the most effective trainers.
- While much of the information is appropriately conveyed in lecture format, hands-on breakout activities and group learning experiences help keep trainees engaged.
- Building rapport and mutual respect among staff and trainees is critical to the learning experience.
While participant evaluations revealed no significant problems regarding the relevance and validity of the training curriculum, we must recognize that trainees cannot comprehensively evaluate the effectiveness of the training due to their lack of experience actually working as CHWs. With this consideration in mind, in September 2014, USA-CRRC conducted an evaluation retreat for CHWs who participated in the first 2 training sessions; 36 CHW trainees participated in the retreat. The primary purpose of the retreat was to gather feedback from trainees regarding their training and posttraining experiences, as well as their views on community needs and approaches to helping their communities meet those needs. Most relevant for our purposes here, participants were asked to evaluate their initial training experience, to identify those training topics that had been most helpful in preparing them to serve as CHWs, and to suggest areas where additional training might be needed. When asked to “evaluate the value of your training when it comes to making a positive difference in your community,” among the total 36 CHW respondents, 86% said it was “very valuable,” 11% said it was “valuable,” and 3% did not answer (Figure). This finding is particularly important in demonstrating that the CHWs' subsequent field experiences did not diminish their positive views of the training they received. When it came to specific training modules that had proved helpful in the field, 4 were identified as “very helpful” by 80% or more of the participants; these included public health, cultural competency, community advocacy, and peer listening. Areas where additional training is needed included more in-depth training on chronic disease management, basics of HIPAA, the Affordable Care Act, cardiopulmonary resuscitation (CPR), and first aid.
Recommendations: Expanding and Refining Training of CHWs
On the basis of these findings, as well as additional feedback, conceptual development, and research, we made significant additional adjustments to our curriculum and have developed recommendations for further changes. To begin, we added several additional components to the CHW curriculum. Because many CHWs will work in clinical settings, we developed a breakout exercise in which the trainees learn to take each other's vital signs, including temperature, respirations, pulse rate, and blood pressure. Not only are these useful practical skills for CHWs but the exercise also provides valuable insights into the role of vital signs in health assessments, an understanding of what constitutes normal readings, and the potential consequences of abnormal readings.
In response to participant suggestions, as well as an additional review of CHW curricula and related research, we determined that CHWs would benefit from training in CPR, the use of automated external defibrillators, and basic first aid. As a result, USA-CRRC contracted with a licensed paramedic and certified CPR instructor to teach a class on these topics as part of the basic training curricula.
Supplemental Training Topics
Approximately 120 million people in the United States have at least 1 chronic disease, so it is not surprising that the management and treatment of chronic disease account for nearly 90% of all health care spending.29 In addition, these conditions result in serious complications when it comes to preparing for, withstanding, and recovering from natural or technological disasters. This is especially the case for disasters that involve spills of hazardous substances, as many chronic conditions can be aggravated or even caused by toxic exposure. Thus, it seems clear that in-depth training on the prevention and management of chronic disease is critical for CHWs. As a result, we developed a separate 36-hour course dealing with 10 of the most common and costly chronic diseases and conditions (arthritis; asthma; cancer; chronic obstructive pulmonary disease; diabetes; HIV/AIDS; heart disease; hypertension; stroke; and mental and behavioral disorders). The curriculum is presented using a rubric that covers the most important and relevant issues (prevalence; general definition; variations; risk factors; potential for prevention; signs and symptoms; diagnosis, prognosis, and complications; treatments and medications; special needs; and roles of lay health workers). USA-CRRC has made this Advanced Training in Chronic Disease Prevention and Management available to all the CHWs who had previously completed training. To date, a total of 84 individuals have been trained.
Our last CHW training in March 2016 was a collaboration between our GRHOP project and CRGC, led by the RAND Corp. RAND has significant experience in building community resilience.22,25,30 Playing upon this strength, we incorporated a new module into the curriculum dealing specifically with that topic. The module was presented by representatives of RAND and included an overview, in-depth concepts, illustrative examples, and a review of community resilience-building projects. This was followed by 2 stand-alone training sessions to help our CRGC CHWs plan and implement individual projects based on identified community resilience-building needs and preferences.
Another area of training critical to the role of CHWs in helping communities deal with disasters involves peer listening. While all disasters cause significant stress, survivors of technological and environmental disasters deal with significant additional stressors, including anxiety associated with ecological contamination and exposure, perceived inequities in claims payments, and potential involvement in formal litigation, all of which may result in the development of “corrosive communities,” characterized by social conflict, hopelessness, and despair.31,32 Peer listener training can help mitigate these negative impacts.33 While we included a peer listener module in our training from the outset, this topic is seldom included in the typical CHW curriculum. We believe it is particularly important that trainees be well versed in the following areas:
- Recognizing variations in consequences and needs depending on postdisaster context;
- Familiarity with the most common psychosocial symptoms (anxiety, depression, posttraumatic stress disorder, substance abuse) and strategies to provide aid;
- Understanding the logistics of good listening and developing appropriate listening and responding skills; and
- Ability to triage survivors based on need, with particular attention on potential referrals to mental health professionals.
A further suggestion is to provide CHWs an overview of the structure and functioning of the US emergency management system. Most of our disaster-related training has focused on preparedness, which is of course valuable but does not sufficiently contribute to the CHWs' appreciation of the “big picture” when it comes to the operation of government during times of crisis. A more complete understanding would allow CHWs to better serve as communication intermediaries between response officials and community members. It would also help build awareness of the potential role they could play in disaster response and recovery. While we have not yet developed an advanced training in this area, there are a number of topics we believe would be key:
- Organization of the emergency management structure in the United States;
- The emergency management cycle: prevention, mitigation, preparedness, response and recovery;
- Variations in context and consequences by type of disaster;
- Effective risk communication: credibility, uncertainty, controversy, potential for conflict, message formulation;
- Postdisaster dangers and operational safety issues; and
- Identifying and publicizing key resources and programs for postdisaster relief.
A final suggestion involves providing a more complete understanding of environmental health risks and resources. This would better prepare CHWs to advocate for community needs before the next disaster, as well as enhance their capacity in the area of disaster response and recovery. An additional module in the basic training of CHWs might include the following topics:
- Developing and implementing environmental health literacy programs;
- Promoting general awareness of local environmental health risks and hazards;
- Publicizing and encouraging participation in environmental activities, workshops, public meetings, etc;
- Identifying and publicizing key resources on environmental health issues; and
- Understanding the causes and consequences of environmental injustice.
CHWs have great potential to contribute to public health in the United States by improving overall community health, motivating maximum emergency preparedness, facilitating postdisaster recovery, and increasing sustainable resilience in anticipation of future disasters. Indeed, they may have advantages over other emergency management actors because they “speak the language of the people,” they have a better sense of community needs and interests, and they enjoy high levels of trust in their communities, all of which enhance their credibility and legitimacy. Maximizing their potential will require curriculum changes as suggested here, as well as a recognition and realization of the utility of CHWs by emergency management officials.
Implications for Policy & Practice
CHWs can make a greater contribution to improving community health and enhancing community disaster resilience through a number of changes in practice and policy:
- It is particularly important to ensure that CHWs receive basic and supplemental training in the following areas:
- Prevention and management of chronic diseases and conditions;
- Recognition of psychosocial symptoms and associated counseling and referral options;
- Concepts and strategies in the area of community resilience building; and
- Environmental health risks and resources.
- In addition, both public health officials and emergency managers should recognize CHWs' potential contributions to their efforts and promote its realization by:
- Networking with CHWs and taking concrete steps to include them in disaster response and recovery teams;
- Facilitating and supporting supplemental training of CHWs as outlined earlier; and
- Encouraging or requiring “responsible parties” to provide funds for the training and placement of CHWs in areas vulnerable to technological disasters as part of their overall mitigation, response, and recovery responsibilities.
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*Examples include (1) https://www.ruralhealthinfo.org/community-health/community-health-workers/3/curriculum; (2) http://www.cachw.org/curriculum/; (3) https://nchwtc.tamhsc.edu/wp-content/uploads/2014/05/CCHD-CHW-Course-Outline.pdf.