Introduction

Community health workers (CHWs) are an effective public health workforce. They operate under a variety of titles including community health representative, outreach worker, and promotores de salud. Through their roles in providing health education, cultural mediation, care coordination, and advocacy [1], CHWs in the U.S. help improve health outcomes [2], reduce emergency department utilization [3], decrease health care costs [4], enhance quality of care [5], reduce health disparities [2, 5], and address social determinants of health [6].

As the evidence of CHWs’ contributions to public health and healthcare interventions mounts, states have become increasingly interested in implementing policy to support strategic expansion of the workforce [7]. The Association of State and Territorial Health Officials (ASTHO) outlines multiple policy issues that each state must attend to including establishing a CHW definition, as well as roles and scope of CHW practice [8]. States must also consider whether and how CHW positions should be funded (e.g. grants or more sustainable mechanisms such as Medicaid). Two other key issues are whether to require CHWs to participate in a standardized training program, as many states have done [9], or go a step further to implement a voluntary statewide CHW certification process, as sixteen states have either begun or successfully completed [10]. Certification is distinct from standardized training in that it requires an administrative body to implement a process for verifying that an individual is qualified, on the basis defined skills or experience, to perform a set of roles or duties [11, 12]. It may also involve training, assessment, and ongoing continuing education [11].

Although there is limited research on how workforce regulations may affect CHWs or health outcomes [12], there are guidelines for developing such policies. Specifically, the American Public Health Association and the National Association of Community Health Workers alike recommend that bodies making decisions about CHW policy should include at least half CHWs [13, 14]. The CDC supports CHW leadership in workforce development efforts [7], including efforts such as the Community Health Worker Core Consensus (C3) Project, which engaged CHWs nationwide to develop a common understanding of CHW roles, skills, and competencies [1].

In 2019 the Louisiana legislature followed national best-practices by creating a CHW Workforce Study Committee (Committee) of at least half CHWs to provide recommendations on how to define, train, finance, and possibly certify CHWs. The head of a CHW professional association known as the Louisiana Community Health Outreach Network (LACHON) and a researcher with over a decade of experience collaborating with Louisiana CHWs led the Committee [15]. Other members included staff from the Louisiana Office of Public Health, Medicaid, and trade associations.

Committee co-leads and staff conducted a statewide study, using a multi-step guide to overcome common challenges in surveying the CHW workforce [16]. The study aimed to inform policy by identifying and describing CHWs’ demographics and work environments and gather insight into employers’ and CHWs’ perspectives on workforce policy issues including CHW roles, training, financing, and certification. This paper describes the Committee’s processes, findings, and recommendations, and offers lessons learned for other states interested in engaging CHWs in workforce development policy decisions.

Methods

In step one (survey planning), the Committee collaborated to define survey objectives. These included establishing a demographic profile of Louisiana CHWs, and gathering CHW and employer input about CHW activities and roles, desire for training, CHW certification, strategies for expanding the workforce, and financing issues. The Committee aimed to survey all CHWs and employers in Louisiana and conduct in-depth interviews with a subset of both groups. Members of the Committee, including CHWs, reviewed a semi-structured interview guide developed by academic team members and survey questions for CHWs and employers, which were based on a tool used for a similar study in another state.

Step 2 (recruitment and retention) began with an existing list of CHWs and employers (e.g. non-profit organizations, Federally Qualified Health Centers, social service agencies, etc.) previously assembled by LACHON. Committee members added to this database the names of individual CHWs, CHW programs, and employers they knew. Academic team members reviewed community resource lists, conducted web-based searches, and made announcements at community meetings to identify additional possible CHWs, programs, and employers. Agencies were approached to verify contact information of all CHWs and employers. Verified CHWs and employers named additional CHWs to be included.

Data collection (Step 3), began at LACHON’s 7th annual conference in September 2019. Roughly 70 CHWs and employers attended and had the option to complete a survey on paper or on a tablet. After the conference, LACHON sent via email an online link to the CHW and employer surveys to conference participants, a LACHON email distribution list, and everyone in the database. Lists were cross-referenced to avoid duplication of emails. Multiple reminders encouraged survey participation and forwarding of survey links to other CHWs and employers. CHWs had the option to complete a paper survey at LACHON monthly meetings in October, November, and December 2019. Data collection ended in December 2019. As an incentive to participate, each group of survey participants (CHWs and employers) was offered the opportunity to enter a raffle for a $50 ClinCard (debit gift card) after completing the survey.

A subset of CHWs and employers working in each region of the state and in a variety of settings was invited (via phone or email, depending on contact information available) to participate in an interview. An experienced CHW interviewed CHWs and a CHW program expert interviewed employers in person or by phone between October and December 2019. Conversations lasted roughly one hour. They were audio-recorded and transcribed verbatim by a professional service. Interviewees were offered a $50 ClinCard as an incentive to participate. This study was reviewed and determined to be non-human subjects research by the Institutional Review Board at Louisiana State University Health Sciences Center – New Orleans. Study participants provided informed consent.

An experienced CHW led quantitative data analysis, (Step 4) using SPSS software (version 26) to tabulate responses and summarize findings. Applied thematic analysis was used to interpret qualitative data [17]. The interviewers developed an initial codebook based on the constructs explored in interviews, and used Atlas.ti (Version 8.4.4), to conduct line by line coding for a subset of two interviews each for supervisors and CHWs. They met to review coding decisions, reconcile differences, and refine the codebook. They then conducted line by line coding and created detailed memos for each interview. They reviewed all coding and memos to identify themes that emerged from the data.

CHWs have been involved in reporting data (Step 5) back to the Committee and to LACHON members, writing a final Committee report to the Louisiana Secretary of Health, as well as dissemination of results (Step 6) and policy-related work (Step 7).

Results

A total of 82 sites that employ 152 CHWs and 56 supervisors in all nine of Louisiana’s public health regions were identified. Sixty-five CHWs and 37 employers participated in the survey. Among 82 CHWs invited to participate in an interview, 24 agreed to participate. Of the 58 who did not participate, 57 did not respond emails or follow-up phone calls, and one declined to participate, citing lack of interest in research participation. Of the 24 who agreed to participate, three initially accepted then did not call in for their interviews or respond to requests to reschedule. Among 27 employers contacted, 15 agreed to participate. Eight employers did not respond, two employers initially accepted but did not respond to scheduling requests, and two employers suggested other people who would be more appropriate interviewees.

The majority of CHWs (67.7%) and employers surveyed (73.0%) identified as female. Five (7.7%) CHWs wrote in their gender as listed in Table 1 below. Among interviewees, 81.0% of CHWs and 86.7% of employers were female. The majority of CHW survey (53.8%) and interview participants (81.0%) were African American/Black. Roughly half of employer interview participants (53.3%) and 40.5% of survey participants were African American/Black. Almost a third of CHWs surveyed had a college degree (30.8%), while over half of employers surveyed held a graduate or professional degree. Similarly, 33.3% of CHW interviewees held a college degree, and 80.0% of employers had a graduate or professional degree. Survey and interview participant demographics are detailed in Table 1.

Table 1 Louisiana CHW workforce study participant demographics
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In terms of their work environment, the majority of CHW survey participants worked in Baton Rouge or the Greater New Orleans area. Roughly nine of 10 CHWs (87.7%) worked full time. The most commonly reported employers were Federally Qualified Health Centers (40.0%), community-based organizations (29.2%) and health departments (10.8%). CHWs reported that their employers typically provided paid time off (73.8%), health/dental insurance (72.3%), and mileage/parking reimbursement or other transportation benefits (69.2%). These results are detailed in Table 2.

Table 2 CHW work environment
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Quantitative Findings

CHWs survey respondents reported that their roles were primarily individual or community outreach and education (80.0%), care coordination (63.1%), conducting outreach (61.5%) participating in community development (55.4%), communicating with clients and providers (50.8%), and conducting individual or community needs assessments (47.7%), among others. The most commonly addressed health issues were mental health (43.1%), HIV/AIDS (41.5%) and diabetes (41.5%).

Roughly half of CHWs had received core competency training (49.2%), while just under half had been trained on HIV/AIDS (44.6%) and community advocacy (43.1%). Roughly 4 in 10 had completed a course in patient navigation (41.5%), diabetes (38.5%) or mental/behavioral health (36.9%). The vast majority of CHWs reported that they were very interested in receiving training in CHW core competencies (83.3%), leadership (88.2%), and community advocacy (83.0%).

The majority of CHWs agreed completely with several statements about the potential benefits of certification including that it could provide them with the opportunity to learn new skills (82.1%), clearly define their role as a CHW (78.6%), and improve job opportunities (80.0%). Over half agreed somewhat or completely with possible concerns about certification including that they would not have the resources to pay for it (68.4%), not wanting non-CHWs to create certification requirements (65.4%), and they already have the skills they need based on their experience (63.2%). CHW perspectives on certification are summarized in Table 3.

Table 3 CHW perceptions of certification
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The majority of employers agreed completely that certification would benefit their organization by helping CHWs learn new skills (81.8%), improving CHWs' work performance (75.8%), and expanding the CHW workforce (72.7%). Almost three-fourths somewhat or completely agreed with possible concerns about certification including that it could change the way community members perceive CHWs (74.2%) or that CHWs would not have the resources to pay to become certified (74.2%). Half of employers also somewhat or completely agreed that certification may create tension between certified and uncertified CHWs (50.0%). Employer perceptions of certification are summarized in Table 4.

Table 4 Employer perceptions of certification
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Qualitative Findings

Three major themes emerged from the interview data. One related to CHWs’ and other stakeholders’ knowledge and perception of CHW roles. Another included the various challenges that CHWs face. Finally, the data revealed varying ideas about how best promote CHW workforce development.

Knowledge and Perceptions of CHW Roles

CHWs primarily described their roles as resource providers and advocates for their clients and communities. As one CHW illustrated, “… I'm an advocate for people in the community…I am an advocate for the people, my Parish.” Another CHW saw her role as an “…advocate for what is important to the clients that I work for…I advocate for improving of their health. I give them resources and I promote their health.”

Despite strong interest in creating new CHW positions in Louisiana, multiple CHWs and employers felt important stakeholders such as the general public, health care systems, state leaders, and even CHWs themselves did not fully understand the CHW profession or roles. As one employer stated, “I think there needs to be an understanding of what this community health worker role is and who is part of it.” Interviewees also revealed that employers may not realize that CHWs have various job titles. For example, one employer pointed out the difficulty with “people understanding that a community health worker, it might be a patient navigator, it might be a peer navigator. It might have a community health educator title, but it's an umbrella term.” Another employer knew someone who also supervised CHWs but declined to participate in the study because they did not realize their staff working under a different title were CHWs.

There was agreement on the need for broad education about the profession. One CHW said: “Let's start with the capitol. Do more education around who community health workers are.” Another CHW felt that, “We have to figure out a way to make individuals understand how they can incorporate CHWs into their organizations…It just takes education, basically, and making people understand how this model works.”

CHW Workforce Challenges

CHWs and employers alike discussed challenges that CHWs face, including limited pay and benefits. Although CHWs and employers believed that CHWs should have access to a full organizational benefit package (e.g. educational stipends, retirement, health insurance, etc.), fair compensation, and basic operating supplies, they agreed that such resources are lacking. One employer noted:

I understand that there is a value of working with people that are passionate about what they are doing. They still need to pay their house and get their needs…That has to go hand and hand with, if you value them, you pay them.

CHWs also expressed a need for more resources for their clients: “It's just that we need more effort put into resources for people that they actually need; grounded in things that are helping the overall health of people.” When unable to meet client’s needs, CHWs reported feeling disappointment, with one stating:

I would like to add that being a CHW is rewarding because you get to connect with the community, but it's also a challenge because you also see the need of the community, and you realize the lack of resources that are available for the need of these families, and you try to take on those issues. You try to save people when you can't.

Additionally, CHWs reported difficulty dealing with the emotional burden and the collective trauma they often navigate, with one CHW stating, “One more challenge is when you see a nine-year-old or an eight-year-old that got shot by a street bullet. It's like, it's a mental challenge. It'll make your day go from seeing the sunshine to seeing thunder and lightning.” Employers reported recognizing this burden, and in response offering debriefing meetings where CHWs can speak freely or providing other means of encouragement. One employer noted:

It’s hard…to do a brain dump and go to the next case and not think about that person you just left…so we have to find ways to let them offload their emotional and mental stress. So, we try to engage them. We give them poems for inspiration. We have little sounding board meetings where they’re free to speak their minds and say the things that are working, not working, just as a mental health refresher.

Promoting CHW Workforce Development

Interviewees expressed a strong interest in developing the CHW workforce in Louisiana, particularly through standardized training, with one CHW stating “I would love to see more CHWs just in the state period, just training [for] CHWs in the state period.” One employer supported training, but only if it were standardized, stating, “I hope it would be standardized. Yeah, that's my only hope. That it would be standardized and evidence-based.” Among employers, one felt that standardized training, “makes us [as a state] stronger”, and another felt, “it would be probably the best situation for us as a state.”

Participants also mentioned specific topics in which CHWs should be trained. One CHW emphasized the importance of cultural humility education saying, “It should cover that cultural part…I don't think everybody understands that there are cultural differences…and meeting them [clients] where they are as far as addressing the social determinants of health.” An employer stressed the importance of CHWs having “…information about the healthcare system, like what's a primary care doctor, what's a specialist, how can members or patients navigate going to the pharmacy, getting their medications, making appointments, accessing resources that help with addressing social determinants of health.”

CHWs and employers expressed a wide variety of positive opinions about the possibility of certifying CHWs in Louisiana. Some believed certification would improve job performance, with one CHW stating, “…it would also make them…more able to help people even more and more efficiently.” Both groups also believed that certification could lead to increased credibility for the profession. One CHW said, “I think it'll give us more prestige within the structure of healthcare.” An employer expressed, “once you're certified, then that says I've gone through a process to achieve a certain level and I've passed a standardized test, so now I am certified and I'm compensated as such.” One CHW said, “I think I support it because that means they're getting continuing education on basically staying up to date on trends and changes.” Interviewees also believed certification would lead to sustainable financing for CHW programs.

Employers and CHWs also expressed several concerns about implementing a certification process. One CHW stated, “I can't say this enough, CHWs do not make a lot. If that cost is something that they have to fork out themselves, sorry, probably will be a problem for them.” CHWs did not want to take an exam to become certified. Both CHWs and employers were concerned about the time that undergoing a certification process could take away from work. Some employers perceived that experienced CHWs were already effective without being certified, noting that “we consider lived experience or connection to the community” as the most important CHW qualification. One stated, “if that person hasn't been in an academic setting for a very long time… but they're good at their job, it may be a deterrent.”

People who were familiar with certification processes in other states expressed concerns such as, “I think just starting some kind of new certification—that means more bureaucracy. So, just navigating that system of getting certification, maintaining that certification.” There was also concern about the possibility of non-CHWs regulating the workforce, with one employer saying:

We have gatekeepers that know their community better than anybody. Who would come up with a certification training, who've never done outreach, who've never engaged the community? And then they're the ones that's putting on this standard or what it should look like. And then never stepped foot in any community at all.

There were also significant misconceptions about CHW certification. Both CHWs and employers demonstrated a lack of knowledge about differences between educational or training certificates and formal credentialing through a certification process. For example, when asked about the possible benefits of standardized training, one CHW mistakenly believed that trainees would be able to “add some letters behind their names.” Similarly, responding to a question about standardized training, one employer said:

I think one of things around CHWs is that they are not being paid enough and consistently…not being able to find funds…because of not having that kind of certification, right? Or a standard certification. It would allow for that to occur if there was a more standard practice around CHWs in Louisiana.

Employers assumed that training would lead to certification, and in turn, reimbursement from Medicaid for CHW services. CHWs believed that certification would lead to increased pay, with one CHW saying, “If you get the certification, supposedly you get the pay with the certification.” Another CHW summed up concerns over the lack of evidence to support these assumptions, stating, “I do know some people who are saying yes we need it. And the question is why. Why do we need it? What will Louisiana get if we have it? What does that mean?”

Although there were concerns and misconceptions around some elements of workforce development, CHWs and employers both expressed strong support for CHW professional associations, with one CHW asking for “…a network of community health workers…an actual meeting place or…an email thread or something with all the community health workers in the city. I feel like it could be really beneficial for all of us to share resources.” Furthermore, employers saw value in CHWs recognizing themselves as members of a professional workforce. They believed this could be achieved by supporting conference attendance, mentoring, and allowing CHWs to participate in professional organizations. An employer noted:

I think we can have more of a coalition where there's meetups for people that are known CHWs and we're coming together, whether it's monthly or quarterly, and just share information with one another because this is new. I know it's new to me and the CHWs in our area. So, if we can meet other CHWs that's been doing this or new as well, and we can all learn from one another.

Discussion

This Louisiana-based study followed nationally-recognized best practices in CHW workforce policy development by including CHW leaders and surveying the workforce about CHW roles, training, financing, and certification. Recommendations based on findings were developed to inform state policy [18].

Overall, findings were consistent with the national CHW landscape, including CHWs’ roles as advocates for their communities, leading the Committee to recommend that all state programs adopt the APHA CHW definition [19] and endorse the roles delineated by the C3 project [1]. Findings also reflected state-specific health needs including Louisiana’s HIV epidemic [20] and lack of behavioral health services [21].

Substantial issues related to lack of stakeholder understanding of the CHW profession indicate a need for broad education about CHW roles and policy. For example, although survey respondents, particularly CHWs, largely demonstrated support for certification, interviews revealed limited understanding of what implementing a certification process would entail or how certification differs from standardized training. It is noteworthy that many positive perceptions of certification, including that it is plausible solution to sustainable financing, increasing CHW pay, and growing the number of CHW positions is not supported by evidence. Furthermore, some survey respondents’ perceived benefits of certification such as increased skills and improved quality of work could arguably result from standardized training. These issues, combined with significant concerns about the potential barriers to obtaining certification (costs, background checks, etc.) or co-optation of the certification process by other professions led the Committee to conclude that implementing a CHW credentialing process in Louisiana in not currently advisable. Instead, the Committee recommended creating a process to evaluate and formally recognize standardized CHW core competency training programs. Additionally, Committee co-leads and staff are currently addressing misinformation about CHW roles and policy by distributing one page-education materials and delivering webinars about best practices for working with CHWs and the differences between standardized training for CHWs and certification processes.

As CHWs continue to be recognized for their ability to address social determinants of health [6], states such as Louisiana seeking to expand the CHW workforce must ensure that CHWs have resources (e.g. utility assistance, food pantries, etc.) to which to refer clients or patients. States may need to strategically invest in resource development and community organizations in advance of implementing CHW programs. They should also establish feedback mechanisms for CHWs, employers, and community leaders to identify and prioritize additional resource needs, particularly in the context of ongoing COVID response and disaster preparation. CHWs must also be allowed as part of their jobs to engage in advocacy on behalf of communities (e.g. educating policymakers and attending public meetings), as such activities can effect positive change in community conditions [22].

This work points to the importance of CHW participation in professional associations. These groups can address many of the issues CHWs and employers raised including the need for CHWs to understand themselves as part of a nationwide workforce and ensuring that any policies governing the profession (e.g. certification) are created by CHWs. They can support CHWs experiencing emotional burden and collective trauma by providing direct support, mentoring, resources, and education. The Committee recommend providing support for CHW professional associations, in part to ensure that such groups can reach CHWs living in all areas of the state.

Ultimately, following national best practices in CHW policy development and survey administration was critical to completing the study and developing CHW-informed policy recommendations. Distributing surveys through LACHON gave the study credibility and capitalized on the trust CHWs and stakeholders have in LACHON as a professional organization and a credible voice for CHWs in Louisiana. Additionally, LACHON’s existing communication infrastructure and connections allowed for identification of CHWs and employers. LACHON leaders and a subset of the Committee continue to meet to plan for implementing recommendations, including creating a CHW financing mechanism through Medicaid.

This study had several limitations. Survey data are cross sectional and purely descriptive. CHWs and employers in rural areas and locations distant from New Orleans and Baton Rouge, where most Committee members work and LACHON has a presence, may not have been identified. Perspectives of CHWs and employers who chose not to participate or were not identified could vary from participants. CHWs with lower levels of education or limited computer literacy skills may have been less likely to respond, and their perspectives may differ from participants. It is not possible to calculate a survey response rate, as unique survey links were not created in order to maximize potential for reaching more participants with a single survey link.

In spite of these limitations, this study provided valuable insight into the current state of the Louisiana CHW workforce. The processes outlined may provide guidance for other states beginning to address CHW workforce development through partnered decision-making between CHWs and policymakers.