Community health workers in Canada and other high-income countries: a scoping review and research gaps.
Najafizada, Said Ahmad Maisam ; Bourgeault, Ivy Lynn ; Labonte, Ronald 等
Community health workers (CHWs) have been deployed in most
countries (whether low-, middle- or high-income) to provide
health-related services to their fellow community members and to guide
them through often complex health systems. They help to address concerns
about how marginalized populations and communities in many countries
experience health inequities that are due, in part, to lack of
appropriate primary health care services, possibly resulting in
inappropriate use of higher-cost health services or facilities. (1-4)
The World Health Organization (WHO) defines CHWs as "members of
communities where they work, selected by and answerable to the
communities for their activities, supported by the health system but not
necessarily a part of its organization, and have shorter training than
professional workers." (5) The 2006 World Health Report identified
the use of CHWs as an important strategy to address the growing shortage
of health workers, particularly in low-resource settings, as well as to
achieve the health-related Millennium Development Goals. (6) The key
research priorities related to CHWs in these settings are to know more
about their recruitment and retention, the specific roles they play with
various levels of the health system, their referral linkages,
communications and the factors improving their performance. (6) In a
follow-up review of CHWs, Lehmann and Sanders addressed the feasibility
and effectiveness of CHW programs, finding that CHWs contributed to both
community development and health care access. (1) Their effectiveness,
however, was determined by their selection, training and support, and
required strong ownership by the community. The question of whether they
should be voluntary or remunerated remained unresolved.
High-income countries such as the US, the UK and Australia have
increasingly attempted to shape CHW roles in their respective health and
social systems in ways that will address some key gaps regarding access
to and appropriate utilization of services, particularly in marginalized
populations. (2-4) Aside from WHO's definition of CHWs, which tends
to be focused on low-and middle-income countries (LMICs), there is no
widely accepted definition of the concept for high-income countries
(HICs). The American Public Health Association has developed a
definition of CHWs that is employed mainly in the US and that loosens
the classic CHW criterion of recruitment exclusively from within local
communities, although specifying that CHWs must have a trusting and
close relationship with the community they serve. (7) We currently know
very little of the role that CHWs play in Canada, despite there being a
number of potentially promising models. (8)
The objectives of our study were to 1) map relevant literature on
different health interventions involving CHWs in a number of HICs (e.g.,
US, UK, Australia, Spain and the Netherlands), including Canada, with a
focus on interventions that have been evaluated; and 2) identify
research gaps in the existing literature on CHWs in Canada in comparison
with CHW interventions in these other HICs.
METHODS
We adopted the five-stage scoping review methodology developed by
Arksey and O'Malley: identifying the research question, identifying
the relevant studies, inclusion and exclusion, charting the data, and
collating, summarizing and reporting the results. (9) Arksey and
O'Malley define a scoping review as
"a technique to 'map' relevant literature in the
field of interest ... [which] tends to address broader topics where many
different study designs might be applicable ... [and] is less likely to
seek to address very specific research questions nor, consequently, to
assess the quality of included studies." (ref 9, p. 20)
Scoping reviews are generally conducted for a number of different
reasons, including identification of research gaps in the existing
literature, which was our objective with reference to Canadian research
literature on CHWs.
We started the review with the question "What do we know about
CHWs in Canada and in other HICs that could inform Canada?" Our
search terms and sources were broad enough to capture all types of study
design. The search process was iterative: as familiarity with the
literature increased, the search terms and sources were redefined to
allow more nuanced searches to be undertaken. Since the concept of CHW
is so broadly defined and defined differently across countries, we
decided to focus our review on CHWs who worked in the fields of health
promotion, disease prevention, access to health services, health
literacy, community development and social determinants of health.
Initially, all MeSH (Medical Sub Headings) and keywords related to CHWs
(Table 1) were identified and a search was conducted in various sources.
Online databases Medline, Embase and CINAHL were searched twice. Google
scholar, the Canadian Health Human Resources Network Library and
websites of Canadian community-oriented health organizations were
searched for grey literature. The search terms picked up a large number
of sources. The initial literature review increased familiarity with the
concept and helped us to develop systematically inclusion and exclusion
criteria. The broader question remained the same, but the definition of
CHW was refined. After the initial search, for example, a number of
concepts such as 'personal support worker', 'home care
workers', and ' long-term care workers' were excluded
from the second round of search. The inclusion and exclusion criteria
(Table 2) resulted in 68 retained sources (Figure 1). The literature was
imported into the software program Refworks.
We then developed a literature extraction tool to obtain key
information from the academic and grey literature. We applied a
qualitative approach using open coding and inductive reasoning to
identify themes in the literature and to develop categories for further
coding and sorting. The data were extracted into an Excel database
sheet. The extracted data were a mixture of general information about
the study and specific information relating, for example, to the type of
CHWs, the geographic area and the population being served, the field of
service by CHWs, and CHW recruitment, training, accreditation and tasks.
For the 68 literature sources, a series of charts were created from
the categories coded in the Excel database. To create each chart, the
number of sources in each category was calculated along with the total
number of sources. A summary of the synthesized findings is reported
below.
[FIGURE 1 OMITTED]
RESULTS
The scoping review included a large number of empirical studies
(excluding evaluation of CHW interventions) followed by evaluation of
CHW interventions (a specific and important type of empirical study) and
literature reviews, with some academic and organizational reports (Table
3). Most sources were from the US (36) followed by Canada (23), the UK
(4), Australia (3), Spain (1) and the Netherlands (1). Most sources
focused on marginalized populations (42) (i.e., Aboriginal peoples,
immigrants and other socially excluded populations). Common areas of
service of CHWs were general health promotion/education, and access to
specific health/disease-focused services and to screening (Table 4). The
most common terms for CHWs were 'community health workers' and
'community health representatives', although nine other titles
were also encountered (Table 5).
Who are CHWs and how are they defined?
Our scoping review suggests that CHWs and the activities they
undertake are best seen as creating connections between the communities
they serve, and health and social service systems. More than 120,000
CHWs are estimated to be working throughout the United States. (10) Most
of these CHWs work in short-term, grant-funded projects targeting
specific health issues such as immunization or health literacy
campaigns. (10) In Canada, there are no such data regarding the number
of CHWs in service, except those working with Aboriginal populations,
and these are known as community health representatives (CHRs). CHRs are
described as "front-line community workers who perform a broad
range of health-related functions ranging from environmental health to
health care delivery, medical administration, counselling and home
visits, education and community development, and mental health."
(ref.11, p.405) Across Canada, there are roughly 1,000 CHRs who serve
First Nations and Inuit communities, 90% of whom are women. (11,12) From
the literature we were able to identify 18 other unique examples of CHW
employment across Canada, although we believe the list is far from
comprehensive (Table 6): it reflects only those CHWs about whom an
article or report has been written.
Recruitment
CHWs in some HICs are recruited by community-based organizations or
by public health organizations with the intent that CHWs are from the
community they serve or have similar living conditions and experiences
as the service population. In Canada, however, CHWs are most commonly
recruited by public health organizations, followed by community-based
organizations, although in both instances emphasis is placed on CHWs
coming from, or being closely linked to, the community they serve.
(13-17) In Aboriginal communities, CHRs are employed by organizations
funded through health care systems to provide primary health services in
remote settings. In urban settings, where communities may be scattered
in different parts of the city, community origin or knowledge about
community is taken into account by the organization deploying CHWs
without the communities necessarily being consulted. (18,19) Aside from
organizational recruitment, there are post-secondary educational
programs intended to train and to lead to employment of Aboriginal CHWs.
(20)
Education and training
The most common type of training for CHWs in HICs discussed in the
literature is on-the-job training, in which CHWs are trained by the
organization that employs them. (21) Health organizational training,
such as certificate programs offered by health departments, and
educational institution training are also widely discussed in the
literature on HICs, although mainly with reference to the US. (21) We
identified three types of education and training for CHWs in Canada:
organizational training programs, institutional training programs, and
on-the-job training. Health organizations in different parts of Canada
have initiated training programs for CHWs to meet the needs of their
population. (16,17) For example, the Cree Board of Health and Social
Services of James Bay, which operates a hospital, social services and
several community clinics, implemented a program to train CHRs.
(12,16,17) Educational institutes such as Confederation College in
Thunder Bay, Ontario, and Alberta Vocational College in Lac La Biche,
Alberta, started CHR training programs in 1988 and 1973 respectively
(16,17) to meet the health needs of First Nations populations in
different parts of the country. The most common type of training in
Canada, as in the US, is on-the-job training, in which organizations
that recruit CHWs for specific purposes train them according to their
needs, such as overall health promotion, (14,19) pregnancy issues (19)
and infant feeding. (15)
Accreditation and recognition
Recognition of CHWs by the health system has two important impacts:
1) it adds credibility to CHW services in the community (15,18,22) and
2) it positively affects their compensation. In the US, 'Community
Health Worker' was included as a standard job classification by the
US Department of Labor in 2010, but only four states (Ohio, Texas,
Minnesota and Massachusetts) have officially recognized the job category
of CHW, (4,21,23) and another four (California, New Mexico, Oregon and
Pennsylvania) have filed or passed legislation to certify or recognize
CHWs. (7) Minnesota has a standardized CHW curriculum to be offered at
colleges and universities, a defined CHW scope of practice and
legislature authorizing reimbursement for the services of trained CHWs
under Medicaid. (4) Inspired by the CHW's role, the UK also
established a public health position in 2004 within its National Health
Service to address health inequalities in the most disadvantaged and
marginalized communities. (2,24) By early 2009, 76% of its primary care
trusts had a service provider named 'health trainer.' National
job descriptions, competencies and a system of accreditation were also
developed simultaneously. (24) In contrast, there remains a lack of
recognition and accreditation of CHWs in Canada. The oldest established
CHW group in Canada comprises CHRs serving mainly First Nations, Inuit
and Metis populations, especially in rural and remote areas; they still
do not have a standard accreditation program. (8,12)
Compensation
CHWs' compensation is strongly linked with their accreditation
and recognition nationally. A national study in the US found that more
than two thirds of CHWs are paid, while there are also volunteer workers
across the country. (21) The study suggests that equitable compensation
for their services is an important step towards CHWs' integration
within the broader health system of the country. In Canada, CHWs are
often compensated by the health organization for which they are working.
(13,17,20,25) They are either employed full-time or part-time, (13,20)
or remunerated for specific services, (25) although some work as
volunteers. (14,26) Sometimes public health departments support a
particular public health program financially but do not pay wages for
CHWs. (22) There is a policy for equitable pay of CHRs in Aboriginal
communities, but band councils have been known to hire CHRs under
different titles in order to pay lower wages than required if the CHR
title had been used. (8,27)
Types of CHW
The types of CHW vary depending on the CHW title, geographic area
and populations they serve, and their area of service. The titles used
for CHWs can be used to identify their types, e.g.,
'promotoras' and 'promotores' are the terms used
for, respectively, female and male CHWs serving Spanish-speaking
populations in the US. CHWs in Canada have various titles. Some terms
refer mainly to the task or focus of these workers (e.g., nutrition
worker, multicultural health worker, home visitor), whereas others
reflect the population they serve. Since language and cultural barriers
decrease appropriate health care utilization and increase inappropriate
utilization, recent immigrants in HICs are a major target group of CHWs.
(28,29)
Tasks undertaken by CHWs
In HICs, CHWs provide a wide range of services according to the
needs of the community and the mandates of the organization they work
with/for. (21,30) In general, CHWs are considered to be a bridge between
communities and the health system. On the one hand, they guide community
members to appropriate services, thus avoiding unnecessary
hospitalization and other acute care while on the other hand they
provide necessary cultural and contextual information for professional
health care providers to build their cultural competence, helping to
improve patient-provider communications. (30)
Most CHW tasks in Canada, like those in other HICs, focus on health
care for the marginalized populations, including improved access to and
utilization of health services, and development and implementation of
health promotion or disease prevention programs. Much of the literature
describes CHR programs targeting the Aboriginal population (12-14,20,31)
or the role of CHRs in improving social capital, cohesion and social
support as important determinants of Aboriginal health. (2,32,33) Other
studies have documented the role of CHWs in maternal health programs,
(15,22) dental health for preschool children, (18) hepatitis B testing,
(25) HIV/AIDS prevention, (27) community development more generally (16)
and nutrition programs. (17) In addition, for research purposes, CHWs
are employed to collect data from the communities they serve
(15,18,22,34) or are identified as key informants regarding those
communities. (11,18,19,32,33,35)
Community knowledge
Community knowledge is essential to the roles of CHWs. First,
community origin or in-depth knowledge of the community is necessary to
build trust, respect and mutual understanding between the CHWs and the
communities they serve. (1,3,4,8) CHWs are thought to understand well
the needs of their communities, mainly because they have lived and/or
experienced those same needs. Second, unlike clinic-based health
workers, CHWs often live in the communities where they work and provide
services whenever required, extending beyond customary working day
hours. (3,4) The importance of having this community knowledge is
usually taken into account at the CHW recruitment stage.
Evaluation studies
Evaluations of CHW interventions in HICs (excluding Canada, where
few such studies exist) generally have three major findings. First, CHW
interventions have positive health outcomes for the population served.
Systematic reviews, empirical studies and meta-analyses demonstrate that
CHW interventions can improve, and have contributed to, a range of
health issues, such as screening among immigrants (28,29,36,37) and
other marginalized populations, (37) diabetes and asthma management,
(36,38,39) healthy heart lifestyle, (40) maternal and child health
services, (41) healthy eating habits, blood pressure reduction, patient
enrolment in research, child development, early intervention services,
(35,42,43) health care utilization, and some disease prevention and
public health concerns. (36,44)
Second, evaluations of CHW interventions have indicated their
potential to reduce health disparities in marginalized populations.
Addressing mainly health issues related to culture, ethnicity, race,
gender and language, CHW interventions have mostly tackled health
inequities among immigrants, Aboriginals, and low income and homeless
populations. (21,24,44,45)
Finally, because of the focus of CHW interventions on primary
health care, health promotion and disease prevention, these
interventions have demonstrated both actual and potential control of
high costs of medical services and inappropriate use of emergency
services when and if CHWs and their interventions are integrated into
health care systems. (46-48)
DISCUSSION
Despite a growing literature on the positive health outcomes of CHW
interventions, CHWs are still a relatively underutilized human resource
in the health care systems in most HICs, including Canada, where they
are both unrecognized and unregulated. (8) This situation in Canada has
been attributed to the lack of "a single definition for CHWs; data
on composition, competencies and size of workforce; a registry of
workers; a national occupational classification; a standard curriculum;
and a common nomenclature."(ref.8, p.308) Complementing the issue
of regulation and recognition of CHWs, there is a large and substantive
literature that recommends formalization of CHWs into broader health and
social service systems for reasons such as reduced health inequity, cost
control and transformation from a disease-centred acute care system to a
system focused on patients and their well-being. (42,46) Below, we
summarize what is known regarding CHWs in HICs (including Canada) and,
on the basis of this information, what remains unknown and important to
ask about the Canadian CHW workforce.
What's known
1. CHWs and CHW interventions have risen out of a need to serve
marginalized communities in HICs. The title they are given may vary,
they may have different training and education, and they may be
remunerated or not. Addressing mainly health issues related to culture,
ethnicity, race, gender and language, CHW interventions have mostly
aimed to tackle health inequities in marginalized populations, such as
immigrants, Aboriginals, and low-income and homeless populations.
(19,21,34,46)
2. There is evidence to suggest that their approach to health is
comprehensive. Their tasks vary from health service navigation and
primary health care and social services provision to community
development and advocacy with respect to the social determinants of
health. (21)
3. Evaluations of CHW interventions in HICs generally indicate
positive health outcomes, reduced health disparity in marginalized
populations, and actual or potential control of high costs of medical
services and inappropriate use of emergency services.
What's not known
1. Despite studies on specific CHW models in Canada (i.e.,
multicultural health brokers in Edmonton, community health
representatives), (13-15,20,26,27,34,41) there is little to no evidence
about the complete picture of CHW interventions across Canada or their
(potential) ability to improve access to primary health care for
marginalized populations and reduce inappropriate use of acute care
services, such as emergency departments.
2. There is little evidence about the role of CHWs in interacting
with organizations that deal with social determinants of health, such as
sanitation, housing, nutrition, job creation, early child development.
3. There is a lack of evidence on the enablers and barriers to
health care and social services navigator roles of CHWs, notably so in
Canada.
4. The cost-effectiveness of CHW interventions in working
alongside, and generally supporting, the provision of medical care
services in primary care or hospital settings is unknown.
CONCLUSION
CHWs throughout the world, and especially in LMICs, are critical
resources in providing primary health care services, increasing access
to formal health care systems, initiating actions on social determinants
of health and working on health promotion and disease prevention
programs aimed at reducing health inequities. Several HICs have
developed policies that have begun to formalize CHW roles within their
health systems.
In Canada, CHWs are sporadically deployed but largely unrecognized,
representing an unregulated public health workforce that is often
marginalized from the formal health care system. This limits the
potential impact CHWs might have in reducing health inequities, linking
marginalized communities to health and social services, and potentially
reducing inappropriate health care utilization. Our scoping review
suggests that CHWs and the interventions they currently undertake are
best seen as bridging the communities they serve and government health
and social service systems. This bridging position has given rise to
different models of CHW organization and practice dependent on how
community-controlled or independent they are, or integrated within
formal health and social service systems. A more thorough mapping and
investigation of the CHW landscape in Canada, and the practice models
CHWs follow, is needed if the potential of CHWs documented in LMICs and
other HICs is to be better realized.
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Received: August 21, 2014
Accepted: December 26, 2014
Said Ahmad Maisam Najafizada, MD, [1] Ivy Lynn Bourgeault, PhD, [2]
Ronald Labonte, PhD, [3] Corinne Packer, PhD, [1] Sara Torres, PhD [4]
Author Affiliations
[1.] Institute of Population Health, University of Ottawa, Ottawa,
ON
[2.] Telfer School of Management and Institute of Population
Health, University of Ottawa, Ottawa, ON
[3.] Faculty of Medicine and Institute of Population Health,
University of Ottawa, Ottawa, ON
[4.] Institut de recherche en sante publique, de l'Universite
de Montreal, Montreal, QC
Correspondence: Said Ahmad Maisam Najafizada, PhD Candidate, 1
Stewart, Room 230, Ottawa, ON K1N 6N6, Tel: [telephone] 613-883-8236,
E-mail:
[email protected]
Conflict of Interest: None to declare.
Table 1. Search terms for community health workers
Community health workers
Community health representatives
Lay health workers
(Women) health educators
Paraprofessional health workers
Community health aides
Promotoras (promotores)
Lay health promoters
Immigrant care workers
Aboriginal health workers
Multicultural health brokers
Lay home visitors
Health trainers
Community navigators
Table 2. Inclusion and exclusion criteria for literature review
Inclusion criteria Exclusion criteria
* Papers published in English * Published in other language
than English
* Papers related to Canada,
US, Australia and Europe
* Papers not related to
* Papers with main focus on Canada, US, Australia and
community health workers Europe
(CHWs)
* Papers not mainly focused on
* Papers focused on health CHWs, (papers with focus on
promotion, disease prevention, personal support workers, home
access to health services, care workers, home health
health literacy, community aides, long-term care workers)
development and social
determinants of health * Papers focused on personal
support care, home care,
* Published after 2005 hospital care and long-term
care
* Published before 2005
Table 3. Study design
Canadian High-income Total
countries number of
articles
Empirical study 7 13 20
Evaluation of intervention 9 9 18
Literature review 4 10 14
Systematic review 4 4
Commentary/opinion 1 8 9
Policy research 5 5
Theoretical 3 0 3
Explorative, experience-based 1 1 2
Academic report 1 1
Table 4. Areas of service of community health workers
Area of service Canada High-income
country
General health Health promotion 12 24
promotion and & education
access Access to health care
Primary health care
Community development
Determinants of health
Specific Diabetes 6
health- Heart health 1
/disease- Mental health 1 1
related studies HIV detection and 1 1
prevention
Maternal and child 6 4
health and nutrition
Other 1 1
Screening Breast cancer screening 1 2
Cervical cancer screening 1 1
Colorectal cancer screening 1
TB screening 1
Hepatitis B testing 1
Cost analysis Cost analysis 1
Research Research 2 1
Area of service Total
General health Health promotion 36
promotion and & education
access Access to health care
Primary health care
Community development
Determinants of health
Specific Diabetes 6
health- Heart health 1
/disease- Mental health 2
related studies HIV detection and 2
prevention
Maternal and child 10
health and nutrition
Other 2
Screening Breast cancer screening 3
Cervical cancer screening 2
Colorectal cancer screening 1
TB screening 1
Hepatitis B testing 1
Cost analysis Cost analysis 1
Research Research 3
Table 5. Type of community health worker
Canadian High-income Total
country
Community health workers 3 30 33
Community health representatives 11 1 12
Lay health workers/ 3 6 9
promoters/advisors
Promotoras (promotores) 3 3
Aboriginal health workers 1 2 3
Community nutrition workers 1 1 2
Community health aides 1 1
Community navigators 1 1
Health trainers 1 1
Paraprofessional home visitors 2 2
Women health educators 2 2
Table 6. Models of community health worker (CHW)
interventions in Canada
Province Organization & title of CHW
British REACH Community Health Centre in Vancouver, BC,
Columbia Cross-Cultural Health Promoter
Umbrella Multicultural Health Co-op in Vancouver, BC,
Cross-Cultural Health Promoter
Alberta Multicultural Health Brokers Cooperative in Edmonton, AB,
Multicultural Health Broker
Manitoba Society for Manitobans with Disabilities in Winnipeg, MB,
Cultural-Resource Facilitator
Manitoba Immigrant Refugee Settlement Section
Association in Winnipeg, MB, Health Committee
BreastCheck Program, Cancer Care Manitoba, Community
Facilitator and Community Support Worker
Welcome Place in Winnipeg, MB
Ontario Healthy Living Division, City of Hamilton Public Health
Services in Hamilton, ON, Women Health Educator
The CASTLE Project (Creating Access to Screening and
Training in the Living Environment)
Latin American Women's Support Organization (LAZO) in
Ottawa, ON, Lay Health Promoters
McMaster School of Nursing in Hamilton, ON, Community
Health Broker
South West Regional Cancer Program in London, ON
Jewish Family Centre in Ottawa, ON, Navigator
Somerset West Community Health Centre in Ottawa, ON,
Multicultural Health Navigator
Projenesis in Ottawa, ON, Lay Health Promoters
Toronto Public Health, Healthy Families Early
Years, Toronto, ON, Peer Educators
Cancer Awareness: Ready for Education and Screening
(CARES) Project in Toronto, ON,Peer Leader/Lay Health
Educator
Quebec Les Relevailles de Saint-Michel in Montreal,
QC, Les marraines
