Community health worker
Encyclopedia
Community health workers (CHW) are members of a community who are chosen by community members or organizations to provide basic health and medical care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...

 to their community. Other names for this type of health care provider
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....

 include village health worker, community health aide, community health promoter, and lay health advisor.

In many developing countries, especially in Sub-Saharan Africa, there are critical shortages of highly educated health professionals. Current medical and nursing schools cannot train enough workers to keep up with increasing demand for health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...

 services, internal and external emigration of health workers, deaths from AIDS
AIDS
Acquired immune deficiency syndrome or acquired immunodeficiency syndrome is a disease of the human immune system caused by the human immunodeficiency virus...

 and other diseases, low workforce productivity, and population growth. Community health workers are given a limited amount of training
Training
The term training refers to the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relate to specific useful competencies. It forms the core of apprenticeships and provides the backbone of content at institutes of...

, supplies and support to provide essential primary health care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...

 services to the population. Programs involving CHW in China, Brazil and Iran have demonstrated that utilizing such workers can help improve health outcomes for large populations in under-served regions. “Task shifting” of primary care functions from professional health workers to community health workers is considered to be a means to make more efficient use of the human resources
Health Human Resources
Health human resources — also known as “human resources for health” or “health workforce” — is defined as “all people engaged in actions whose primary intent is to enhance health”, according to the World Health Organization's World Health Report 2006. Human resources for health are identified as...

 currently available and improving the health of millions at reasonable cost.

History

Scientific medicine has evolved
History of medicine
All human societies have medical beliefs that provide explanations for birth, death, and disease. Throughout history, illness has been attributed to witchcraft, demons, astral influence, or the will of the gods...

 slowly over the last few millennia and very rapidly over the last 150 years or so. As the evidence mounted of its effectiveness, belief and trust in the traditional ways waned. The rise of university based medical school
Medical school
A medical school is a tertiary educational institution—or part of such an institution—that teaches medicine. Degree programs offered at medical schools often include Doctor of Osteopathic Medicine, Bachelor/Doctor of Medicine, Doctor of Philosophy, master's degree, or other post-secondary...

s, the increased numbers of trained physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

s, the professional organizations they created, and the income and attendant political power they generated resulted in license regulations
Healthcare provider requisites
Healthcare provider requisites refer to the regulations used by countries to control the quality of individual healthcare workers practicing in their jurisdictions and to control the size of the health labour market...

. Such regulations were effective in improving the quality of medical care but also resulted in a reduced supply of clinical care providers. This further increased the fees doctors could charge and encouraged them to concentrate in larger towns and cities where the population was denser, hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....

s were more available, and professional and social relationships more convenient.

In the 1940s Chairman Mao Tse Tung in China faced these problems. His anger at the “urban elite” medical profession over the maldistribution of medical services resulted in the creation of "Barefoot doctors
Barefoot doctors
Barefoot doctors are farmers who received minimal basic medical and paramedical training and worked in rural villages in the People's Republic of China. Their purpose was to bring health care to rural areas where urban-trained doctors would not settle...

". Hundreds of thousands of rural peasants, chosen by their colleagues, were given rudimentary training and assigned medical and sanitation duties in addition to the collective labor they owed the commune. By 1977 there were over 1.7 million barefoot doctors. As professionally trained doctors and nurses became more available, the program was abolished in 1981 with the end of agricultural communes. Many Barefoot Doctors passed an examination and went to medical school. Many became health aides and some were relieved of duty.

Brazil undertook a medical plan named the Family Health Program
Programa Saúde da Família
The Programa Saúde da Família , Family Health Program, in Portuguese language is one of the national public health programs in Brazil, which implements a national policy for primary care settings with the aim of substituting part of the traditional model of primary care based on medical specialists...

 in the 1990s that made use of large numbers of community health agent
Community health agent
Community health agent is the title of a specific lay health care worker developed in Brazil by way of PACS in 1991 as part of the construction of the Brazilian Unified Health System established by Constitutional rule in 1988.The agent, which was said to be inspired on the barefoot...

s. Between 1990 and 2002 the infant mortality rate dropped from about 50 per 1000 live births to 29.2. During that period the Family Health Program increased its coverage of the population from 0 to 36%. The largest impact appeared to be a reduction of deaths from diarrhea
Diarrhea
Diarrhea , also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and...

. Though the program utilized teams of physicians, nurses and CHWs, it could not have covered the population it did without the CHW. Additionally there is evidence in Brazil that the shorter period of training does not reduce the quality of care. In one study workers with a shorter length of training complied with child treatment guidelines 84% of the time whereas those with longer training had 58% compliance.

Iran utilizes large numbers of para-professionals called behvarz. These workers are from the community and are based in 14,000 “health houses” nationwide. They visit the homes of the underserved providing vaccinations and monitoring child growth
Growth chart
A growth chart is used by pediatricians and other health care providers to follow a child's growth over time. Growth charts have been constructed by observing the growth of large numbers of normal children over time...

. Between 1984 and 2000 Iran was able to cut its infant mortality
Infant mortality
Infant mortality is defined as the number of infant deaths per 1000 live births. Traditionally, the most common cause worldwide was dehydration from diarrhea. However, the spreading information about Oral Re-hydration Solution to mothers around the world has decreased the rate of children dying...

 in half and raise immunization rates from 20 to 95%. The family planning
Family planning
Family planning is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and...

 program in Iran is considered highly successful. Fertility has dropped from 5.6 lifetime children per woman in 1985 to 2 in 2000. Though there are many elements to the program (including classes for those who marry and the ending of tax incentives for large families), behvarz are extensively involved in providing birth control advice and methods. The proportion of rural women on contraceptives in 2000 was 67%. The program resulted in profound improvement in maternal mortality going from 140 per 100,000 in 1985 to 37 in 1996.

Scope of Community Health Worker Programs

The World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

 estimates there are over 1.3 million community health workers worldwide. In addition to the large scale implementation by countries such as China, Brazil, and Iran, many countries have implemented CHW programs in small scale levels for a variety of health issues.

In India, community health workers have been utilized to increase mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

 service utilization and decrease stigma associated with mental illness. In this program respected female members of the community were chosen to participate. All of the women were married, came from a good social standing, displayed a keen interest in the program, and were encouraged by their family to participate. The women chosen were then trained in identification and referral of patients with mental illnesses, the common myths and misconceptions prevalent in the area and in conducting community surveys. The training lasted 3 days and included lectures, role plays and observation of patient interviews at the psychiatry
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...

 outpatient department at St. John’s Medical College Hospital. A population of 12,886 were surveyed using a brief questionnaire. Out of this population 574 were suspected patients. Out of this 242 suspected patients visited the clinic after follow up from the community health worker.

In Tanzania, village health workers were part of a community-based safe-motherhood approach. The VHWs assisted pregnant
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

 women with birth planning, which included timely identification of danger signs, preparation and accumulation of two or more essential supplies such as soap, razors, gloves for clean delivery, and mobilizing household resources, people and money to manage a possible emergency. Approximately one year after the CBRHP's major interventions ceased in these communities, most of the VHWs continued to do health promotion
Health promotion
Health promotion has been defined by the World Health Organization's 2005 Bangkok Charter for Health Promotion in a Globalized World as "the process of enabling people to increase control over their health and its determinants, and thereby improve their health"...

 by visiting pregnant women, teaching them about birth planning and danger signs, and assisting them in obtaining both prenatal and obstetric services. Local VHW associations are forming with support from local political leaders, the Ministry of Health, and the non-governmental organization CARE to sustain the work of the VHWs. The community development officers, some of who were also the master trainers, are involved in spearheading the formation of VHW organizations.

The use of CHWs is not limited to developing countries. In New York, CHWs have been deployed across the state to provide care to patients with chronic illnesses like diabetes that require sustained, comprehensive care. They work in both rural communities where access to primary care is sparse, and in urban communities where they are better able to bridge communication gaps that may arise between patients and doctors. They are seen to play an important role in assisting patients with navigating a complex, uncoordinated health care system
Health care system
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations....

.

A randomized controlled intervention on the U.S.-Mexico border, used promotoras
Promotoras
Promotoras are Hispanic community health worker who work within their communities to educate target audiences about health issues affecting those communities. Promotoras live in the communities in which they work, so they have an understanding of neighborhood and individual health, social issues...

or “female promoters” to increase the number of women utilizing routine preventive examinations. The control group received a postcard reminding women to get preventive screening. The free comprehensive clinical exam included a Pap test, a clinical breast exam, human papillomavirus
Human papillomavirus
Human papillomavirus is a member of the papillomavirus family of viruses that is capable of infecting humans. Like all papillomaviruses, HPVs establish productive infections only in keratinocytes of the skin or mucous membranes...

 (HPV) testing, blood draw for total cholesterol and blood glucose, and a blood pressure measurement. The other group received the same postcard and a follow-up visit from a promotora. The group that was followed up by a promotora
Promotoras
Promotoras are Hispanic community health worker who work within their communities to educate target audiences about health issues affecting those communities. Promotoras live in the communities in which they work, so they have an understanding of neighborhood and individual health, social issues...

 saw a 35% increase in visits to get the free screening.

Community health workers have also been utilized to assist in research. Martin et al. found that the Latin-American population in the United States frequently does not benefit from health programs due to language barriers, distrust of the government, and unique health beliefs and practices, and specifically that providing effective asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...

 care to the Latino population is an enormous challenge. In addition they found that Latinos are also often excluded from research due to a lack of validated research instruments in Spanish, unsuccessful study recruitment, and a limited number of Latino researchers. Thus, Martin and colleagues decided to used community health workers to recruit participants. To gauge the effectiveness of their recruitment strategy to other more traditional recruitment models they looked at two studies. Both these studies offered significant monetary incentives for participation while the CHW study offered nothing for the initial participation. Martin et al. found that individuals who chose not to participate in the study went on to receive other services in the areas of diabetes and cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...

 prevention, which was not the case for the other studies.

Current status

Cost and access to medical care remain problems of worldwide scope. They are particularly severe in the developing world and it is estimated one million more health care workers are needed in Africa to meet the health-related Millennium Development Goals
Millennium Development Goals
The Millennium Development Goals are eight international development goals that all 193 United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015...

. Doctors are few and concentrated in cites. In Uganda some 70% of medical doctors and 40% of nurses and midwives are based in urban areas, serving only 12% of the population. Medical training is long and expensive. It is estimated that to meet health workforce needs using the American or European model, Africa would need to build 300 medical schools with a total training cost of over $33 billion and it would take over 20 years just to catch up. In many countries salaries of doctors and nurses are less than that of engineers and teachers. Bright young medical professionals often leave practice for more lucrative opportunities. Emigration of trained personnel to countries with higher salaries is high. In Zambia of the 600 doctors trained since independence it is estimated only 50 practice in their home country. In some countries AIDS is killing experienced nurses and doctors amounting to 30-50% of the number trained yearly. Though many countries have increased their spending on health care and foreign money has been injected, much of it has been on specific disease-oriented programs. Health systems remain extremely weak, especially in rural areas. The World Health Assembly
World Health Assembly
The World Health Assembly is the forum through which the World Health Organization is governed by its 194 member states. It is the world's highest health policy setting body and is composed of health ministers from member states....

 in 2006 called for, “A health workforce which is matched in number, knowledge and skill sets to the needs of the population and which contributes to the achievement of health outcomes by utilizing a range of innovative methods”.

Community health workers are thought to be part of the answer. They can be trained to do specialized tasks such as provide sexually transmitted disease
Sexually transmitted disease
Sexually transmitted disease , also known as a sexually transmitted infection or venereal disease , is an illness that has a significant probability of transmission between humans by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex...

 counseling, directly observed therapy for tuberculosis control, or act as trained birth attendant
Birth attendant
A birth attendant, also known as “skilled birth attendant” , is a midwife, physician, obstetrician, nurse, or other health care professional who provides basic and emergency health care services to women and their newborns during pregnancy, childbirth and the postpartum period...

s. Others work on specific programs performing limited medical evaluations and treatment. Others have a far broader primary care function. With training, monitoring, supervision and support such workers have been shown to be able to achieve outcomes far better than baseline and in some studies, better than physicians.

Important attributes of community health workers are to be a member of and chosen by the community they serve. This means they are easily accepted by their fellows and have natural cultural awareness. This is crucial because many communities are disengaged from the formal health system. In Sub-Saharan Africa 53% of the poorest households do not seek care outside the home. Barriers include clinic fees, distance, community beliefs and the perception of the skills and attitudes of medical clinic workers. Community health workers are unable to emigrate because they do not have internationally recognized qualifications. Finally, the variation in incentives between areas of the country tends to be low. All these factors combined with strong community ties, tend to result in retention at the community level.

Much remains to be learned about the recruitment, training, functions, incentives, retention and professional development of community health workers. Learning developed in one country may not be applicable to another due to cultural differences. Health worker adaptability to local requirements and needs is key to improving medical outcomes. That being said, it has been estimated that six million children’s lives a year could be saved if 23 evidence based interventions were provided systematically the children living in the 42 countries responsible for 90% of childhood mortality. Over 50% of this benefit could be obtained with an integrated, high-coverage, family-community care based system. Community health workers may be an integral and crucial component of the health human resources
Health Human Resources
Health human resources — also known as “human resources for health” or “health workforce” — is defined as “all people engaged in actions whose primary intent is to enhance health”, according to the World Health Organization's World Health Report 2006. Human resources for health are identified as...

 team needed to achieve such goals.

See also

  • Health care provider
    Health care provider
    A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....

    s
  • Health human resources
    Health Human Resources
    Health human resources — also known as “human resources for health” or “health workforce” — is defined as “all people engaged in actions whose primary intent is to enhance health”, according to the World Health Organization's World Health Report 2006. Human resources for health are identified as...

  • Barangay Health Volunteers
    Barangay Health Volunteers, Philippines
    The Barangay Health Volunteer, also known as Barangay Health Worker, is a category of health care providers in the Philippines. They undergo a basic training program under an accredited government or non-government organization, and render primary care services in the community...

     in the Philippines
  • Community health agent
    Community health agent
    Community health agent is the title of a specific lay health care worker developed in Brazil by way of PACS in 1991 as part of the construction of the Brazilian Unified Health System established by Constitutional rule in 1988.The agent, which was said to be inspired on the barefoot...

     in Brazil
  • Lady Health Worker in Pakistan
  • Health Extension Worker
    Health Extension Officer
    Health Extension Officers, also known as Health Extension Workers , are a category of health care providers found in some countries including Papua New Guinea and Ethiopia...

     in Ethiopia
  • Physician shortage
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