Abstract
Objectives. To establish a validated, standardized set of core competencies for community health workers (CHWs) and a linked workforce framework.
Methods. We conducted a review of the literature on CHW competency development (August 2015), completed a structured analysis of literature sources to develop a workforce framework, convened an expert panel to review the framework and write measurable competencies, and validated the competencies (August 2017) by using a 5-point Likert scale survey with 58 participants in person in Biloxi, Mississippi, and electronically across the United States.
Results. The workforce framework delineates 3 categories of CHWs based upon training, workplace, and scope of practice. Each of the 27 competencies was validated with a mean of less than 3 (range = 1.12–2.27) and a simple majority of participants rated all competencies as “extremely important” or “very important.”
Conclusions. Writing measurable competencies and linking the competencies to a workforce framework are significant advances for CHW workforce development.
Public Health Implications. The standardized core competencies and workforce framework are important for addressing health disparities and maximizing CHW effectiveness.
Community health workers (CHWs) have long been an essential component of the US public health workforce.1,2 They effectively manage chronic disease, promote health, and facilitate access to health care, particularly with underserved populations.2–4 In the last decade, the CHW workforce has expanded, in part because of the 2010 Affordable Care Act5 and recognition of the CHW model as a strategy for promoting community–clinic linkages.6 Our knowledge of CHW workforce composition is growing,1 but its recent expansion has left some gaps—(1) unclear scopes of practice among CHWs and (2) a lack of measurable, standardized CHW core competencies—both important elements of public health workforce development.7 As with all public health programs or services, the effectiveness of the CHW model is partially dependent on workforce competency. It is essential to address these workforce gaps as CHW employment is expected to expand 18% by 2026.8 To this end, the purpose of this study was to establish a community health workforce framework and linked measurable, validated, and standardized CHW core competencies.
The American Public Health Association (APHA) defines a CHW as the following:
a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.9
Despite this widely accepted definition, there is considerable variability in CHW workplaces, in terms of organization (e.g., community health centers, nonprofits, health ministries, public health agencies) and location (e.g., rural vs urban).10 As such, “community health worker” often serves as an umbrella term encompassing diverse roles and job titles for unlicensed public health workers ranging from community-based outreach specialists to patient navigators integrated within clinical health care teams.11 Groundbreaking work to develop the first set of CHW competencies took place 20 years ago with the National Community Health Advisor Study.12 In 2010, the US Bureau of Labor Statistics recognized CHW as an occupation.13 More recently, state legislation has led to policies about CHW roles, curricula, and certification processes.14 All of these efforts have resulted in a plethora of curriculum objectives, competencies, and roles for CHWs that employers and instructors can draw upon for hiring and training. However, no measurable, standardized CHW competencies have been published in the peer-reviewed literature to date. Standardized core competencies are important for addressing health disparities, maximizing CHWs’ effectiveness, and further establishing CHWs as health professionals.15 Moreover, a workforce framework is beneficial for describing scopes of practice and directing training for CHWs’ diverse roles and work settings.
We used competency-based education to guide this study. Competency-based education, often used in public health,16 focuses on the outcomes of learning and prepares health professionals for future practice needs.17 In competency-based education, competencies are standards for developing curriculum, teaching, and evaluating learner or worker performance. A competency is
a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility) that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.18(p124)
Each competency should have 5 characteristics:
Focus on the performance of the end-product or instructional goal,
Reflect what is learned in the instructional program,
Be expressed in terms of measurable behavior,
Use a standard for judging competence independent of others’ performance, and
Inform learners and other stakeholders about what is expected of them.19
We adhered to these tenets to develop CHW core competencies. Indeed, we created guidelines for writing competencies for measurable behavior. This is a unique aspect of this study’s approach, especially when one considers that many competency sets are written in ways that make assessment difficult. For example, the state of Texas has a competency area, “Broad knowledge about the community,” which is considered part of a CHW’s necessary knowledge base of specific health issues. As written, this competency does not convey (1) what community the CHW should know about, (2) what type of knowledge is required, (3) what a CHW might need to do with this knowledge, or (4) how a CHW should demonstrate knowledge. This puts an employer or instructor in the position of having to interpret these issues and then assess competency on the basis of that interpretation.
Our methodology consisted of (1) a literature review, (2) structured analysis of literature sources and development of the workforce framework, (3) expert panel development of competencies, and (4) validation of competencies.
We conducted a literature review in August 2015 to locate peer-reviewed literature on CHW competency development. The purpose of the review was to survey the recent literature to provide background information for the expert panel developing the competencies. We carried out searches in CINAHL, PubMed, PsycInfo, Social Sciences Full Text, and MedicLatina databases with terms commonly used to describe CHWs (e.g., community health worker, lay health worker, patient navigator) and competencies (e.g., competency, competencies, core competencies). We also completed a targeted Internet search for competencies or training standards from the 5 states (MA, NM, OH, OR, TX) in 2015 with regulations for CHW certification.20 Finally, we conducted an Internet search for competencies in fields sharing certain roles with CHWs.
Ultimately, we located the following sources: (1) 12 peer-reviewed articles published between 2007 and 2015 detailing competency development or training standards; (2) 5 state-based documents outlining competencies, curriculum, or certification training requirements; and (3) 3 competency sets for health education, prevention, and public health (Appendix A, available as a supplement to the online version of this article at http://www.ajph.org).
We carried out a structured analysis of the literature sources by responding to questions about each—for example, Are competencies listed in the document? How were the competencies developed? Are the competencies validated? What is the audience for the competencies? What is the scope of practice, work setting, and type of training of the target audience? If no competencies are listed, what is the focus? We tracked results in an Excel spreadsheet. The structured analysis revealed overlapping, yet distinct characteristics of CHW scope of practice, workplace, and training, which were integrated into a draft community health workforce framework. We modeled this framework after the Council on Linkages Between Academia and Public Health Practice’s Core Competencies for Public Health,21 which has 3 tiers to identify career stages for public health professionals. We focused on establishing competencies for a midlevel CHW (category 2) as the knowledge, skills, and attitudes serve as a platform from which competencies can later be built down or up for categories 1 or 3 (Figure 1). A similar approach was used for developing competencies for applied epidemiology and public health informatics.22,23
FIGURE 1— Community Health Workforce Framework: United States, 2017
Note. CHW = community health worker.
The second step of structured review consisted of a side-by-side comparison of competency domains present in the 20 literature sources. A domain is a “broad distinguishable area of competence that in the aggregate constitutes a general descriptive framework for a profession.”24(p1089) We then drafted an initial set of competency domains for this study on the basis of the results of the comparison, relevance to the APHA’s definition of a CHW, and the scope of practice for category 2 of the proposed workforce framework.
We convened a national expert panel of 15 individuals in fall 2015 to review the workforce framework, finalize the domains, and write the core competencies. The panel consisted of 6 CHWs and CHW supervisors, 4 academic researchers, 2 physicians, and 3 public health practitioners with expertise in communications, nursing, public health, workforce development, competency development, chronic disease management, and applied health sciences. The CHWs and supervisors on the panel worked in southeast Louisiana in federally qualified health centers. Working remotely, the expert panel examined the draft framework and domains.
The panel participated in a 2-day in-person workshop in December 2015 to finalize the domains, write draft competencies, and discuss the framework. The panel worked in small groups to write competencies for the proposed domains and then jointly discussed their work. During this discussion, the panel made many revisions; for example, domains were renamed, domains and competencies were collapsed, competencies were moved to different domains, and items were discarded for irrelevance or duplication. In writing competencies, the panel utilized Bloom’s Taxonomy,25 which views learning on a continuum beginning with knowledge, the most basic level, and progressing through comprehension, application, analysis, synthesis, and, finally, evaluation, the most complex level. The panel determined that knowledge, comprehension, and application best correlated with the scope of practice for category 2 CHWs. This level corresponds with verbs such as name, define, recognize, identify, describe, inform, prepare, and demonstrate. The panel used these or similar verbs when writing competencies, and we introduced additional guidelines for writing measurable statements to enhance learner assessment (Table 1).
TABLE 1— Guidelines for Writing Measurable Competencies: United States, 2017
| Guideline | Rationale | Example of Competency in Need of Revision | How to Revise a Competency | Example of a Revised Competency |
| Each competency statement should contain only 1 verb. | Multiple verbs indicate multiple competencies in 1 statement, making assessment more difficult. | Identify and engage stakeholders. | Split the competency into 2 competencies. | Identify stakeholders. |
| Engage stakeholders. | ||||
| Each competency statement should include just 1 task or role. | Double-barreled or compound competencies indicate multiple competencies in 1 statement, making assessment more difficult. | Engage community partners and clinic operators. | Split the competency into 2 competencies or reword the competency to simplify, but still allow for assessment. | Engage community partners. |
| Engage clinic operators. | ||||
| OR | ||||
| Engage stakeholders. | ||||
| Each competency statement should be measurable. | Measurable competencies allow for more precise evaluation of employee performance. | Be acquainted with stakeholders. | Replace the vague, difficult-to-measure verb with a more precise, measurable verb. | Identify stakeholders. |
| No competency statement should contain modifiers, such as adequate, appropriate, or suitable. | Modifiers imply that standards can vary. Standards should be clearly stated. From a performance perspective, for example, an employer would always want an employee to perform a task adequately, not inadequately. | Engage appropriate stakeholders. | Remove modifier from the competency. | Engage stakeholders. |
| Each competency statement should appear only once in the entire set of competences. | Overlapping competencies indicate that the domains are repetitive or redundant. Each domain should stand alone. | “Engage stakeholders” competency is listed under 2 domains: community health practice and communication. | Reassess or refine domain definitions or delete the competency from 1 of the domains. | “Engage stakeholders” now only listed under the community health practice domain. |
The workforce framework was the subject of much discussion by panelists. Originally, the framework had 4 categories, but the panel eliminated the fourth category (similar to a nurse navigator) as it strayed into clinical care. The panel then revised the remaining 3 categories, with specific focus on describing the scopes of practice (Figure 1) and emphasizing that the framework should function as a continuum.
After the meeting, we revised the panel’s draft competencies to ensure that they followed, as much as possible, the guidelines for writing competencies (Table 1). For example, we rewrote competencies with 2 verbs (indicating there were 2 behaviors to measure within 1 competency) with just 1 verb or split them into 2 competencies. We circulated the revised competencies electronically and then conducted 2 conference calls for review by panelists. By April 2016, the panel had written 27 competencies in 6 domains.
The draft competencies were validated by CHWs as well as CHW supervisors, instructors, and researchers with a modified Delphi technique, commonly used to validate competencies for health professions.26 Using a survey with a 5-point Likert-type scale, participants rated the importance of the competencies as “extremely important,” “very important,” “moderately important,” “slightly important,” or “not at all important.” Participants also provided qualitative comments to inform further rounds of revision and validation, if necessary. The survey was completed by 58 individuals—27 completed a paper survey in February 2017, and 31 completed an online survey using the Research Core survey platform (Qualtrics, Seattle, WA) in August 2017. We administered the paper survey at an annual meeting held in Biloxi, Mississippi, of CHWs and CHW supervisors from coastal areas of Louisiana, Mississippi, Alabama, and Florida.10 We identified online participants through an Internet search for trainers, course instructors, and members of CHW associations and boards in the United States broadly and in 18 states with regulations pertaining to the CHW workforce.14 We also identified participants by reviewing the presenters for the CHW section at APHA’s annual meeting and the Center for Sustainable Health Outreach Unity Conference in 2016 and 2017. We excluded potential participants if a valid e-mail address was not publicly available or it was not evident that the individual had worked in the field. We invited a total of 194 participants to complete the online survey, which was available for 2 weeks.
We entered survey responses in Excel 2016 (Microsoft, Redmond, WA) and analyzed them with SPSS version 24 (IBM, Somers, NY). We calculated descriptive statistics for each competency and entered qualitative comments in a spreadsheet, categorizing them by domain and then theme. If a simple majority (51%) of participants considered a competency to be extremely important or very important (mean rate < 3), we retained it in the competency set without modifications. We planned to exclude any competency rated moderately important, slightly important, or not at all important (mean rate ≥ 3).
Results are reported for both the community health workforce framework and the validation of competencies.
The community health workforce framework (Figure 1) delineates 3 categories of workers on the basis of training, work setting, and scope of practice. The framework functions as a continuum, and, in practice, workforce members could have overlapping areas of responsibility, especially among categories 1 and 2 and categories 2 and 3. The framework implies increasing specialization in terms of training and scope of practice, but it is not a hierarchy, and each category fulfills equally important community health needs. All CHWs, regardless of category, should complete a core competency training, augmented by training specific to work setting and scope of practice. With the appropriate training, one can enter the workforce at any category without needing to work up the ladder, so to speak.
Category 1 represents CHWs with the health outreach and advocacy knowledge and skills for providing health information, promoting awareness, and conducting outreach. Category 1 workers often address barriers to general health and well-being, such as housing, transportation, and access to food and recreation, rather than specific health conditions. They work in multiple community settings such as nonprofit community-based organizations, faith-based ministries, and grassroots organizations, but they do not usually work in a structured health care unit. Category 1 workers conduct on-the-ground outreach and provide health information within the community, at client’s homes, and at community health events.
Category 2 workers conduct outreach within the community, form community partnerships, facilitate access to primary care services, and implement community health activities. They are typically embedded in primary care clinics, federally qualified health centers, and community-based health organizations. The defining characteristic that separates category 2 from category 1 is the focus on specific health conditions rather than general health issues. Category 2 CHWs receive training focused on chronic conditions, in addition to core competency training.
The scope of practice of a category 3 CHW is focused on a specific disease, such as a cancer navigator or an asthma counselor. They work in ambulatory care settings, federally qualified health centers, or mobile clinics, and link acute and ambulatory care. They are trained in the disease or health condition of their clients and may use evidence-based research to manage clients’ health needs. They address barriers to care for clients, provide clients with disease- and treatment-specific information, and coordinate care.
Survey participants resided in 22 states, with 66% from 6 states in the south (AL, FL, MS, LA, GA, TX). Their job titles were CHW (47%), CHW supervisor (29%), CHW instructor (16%), and CHW researcher (9%). Most worked for nonprofit organizations (45%) and health clinics or systems (21%), while the remainder worked at universities, community or technical colleges, and government. The mean amount of time working in the CHW field was 8 years; 57% had 1 to 5 years’ experience, 24% had 6 to 15 years, and 16% had 16 or more years.
The 6 competency domains and definitions are presented in the box on this page. Each of the competencies had a mean of less than 3, and a simple majority of participants rated all competencies as “extremely important” or “very important” (Table 2). As all competencies met the threshold for inclusion, all were retained, and no further validation was necessary. Overall, 67% of the competencies (n = 18) had means of 1.5 or less, ranking them as “extremely important.” All competencies in the diversity and inclusion domain were ranked “extremely important.” The 2 competencies with the lowest means (1.12), and thus ranked as the most important, were from community health practice (B6) and diversity and inclusion (D3). The 4 competencies with the highest means (ranging from 2.0 to 2.27), and thus deemed the least important, but still “very important,” were all from assessment (A1, A2, A3, and A4). The remaining 21 competencies had means ranging from 1.14 to 1.91.
| Domain | Definition |
| Assessment | Apply assessment data to community health actions at client and community levels. |
| Community health practice | Implement health promotion strategies within communities. |
| Communication | Gather and exchange information with clients and community stakeholders. |
| Diversity and inclusion | Respect the range of differences among individuals and communities. |
| Professional practice | Perform within an organization. |
| Disease prevention and management | Implement strategies to reduce the burden of preventable disease. |
TABLE 2— Consensus of Importance of Community Health Worker Core Competencies: United States, 2017
| Core Competency | Meana | % Ranking as 1 or 2b | Consensus for Inclusion |
| A. Assessment | |||
| 1. Identify available sources of health data | 2.14 | 72 | Yes |
| 2. Demonstrate program effectiveness with data | 2.00 | 74 | Yes |
| 3. Prepare reports by using electronic medical records and unified data | 2.27 | 59 | Yes |
| 4. Integrate findings of data assessment into clinic operations | 2.23 | 66 | Yes |
| B. Community health practice | |||
| 1. Identify stakeholders to support community outreach | 1.34 | 98 | Yes |
| 2. Engage community partners around programs and activities | 1.38 | 97 | Yes |
| 3. Organize client education opportunities | 1.36 | 98 | Yes |
| 4. Arrange community health events | 1.78 | 78 | Yes |
| 5. Facilitate clients’ access to health services | 1.14 | 100 | Yes |
| 6. Advocate for clients’ needs | 1.12 | 100 | Yes |
| C. Communication | |||
| 1. Communicate with linguistic and cultural proficiency (e.g., in writing, orally, and visually) | 1.18 | 85 | Yes |
| 2. Distribute health information to community and clients | 1.47 | 90 | Yes |
| 3. Disseminate information about health programs and policies | 1.65 | 88 | Yes |
| D. Diversity and inclusion | |||
| 1. Describe diversity as it applies to communities (e.g., race, gender, religious beliefs, national origin, ethnicity, age, disability, political beliefs, sexual orientation, gender identity, gender expression, family status, socioeconomic level) | 1.35 | 72 | Yes |
| 2. Identify health disparities within communities | 1.45 | 91 | Yes |
| 3. Function without judgment, bias, or stereotype | 1.12 | 97 | Yes |
| E. Professional practice | |||
| 1. Adapt to multiple responsibilities | 1.45 | 98 | Yes |
| 2. Recognize the role of CHWs and other members of a health care team | 1.29 | 98 | Yes |
| 3. Apply continuing education to work responsibilities | 1.67 | 83 | Yes |
| 4. Incorporate ethical standards of practice into all interactions with individuals, organizations, and communities | 1.18 | 98 | Yes |
| 5. Operate programs within a budget | 1.91 | 71 | Yes |
| F. Disease prevention and management | |||
| 1. Identify factors that influence access to disease prevention and management services | 1.49 | 88 | Yes |
| 2. Share information about disease prevention and management | 1.41 | 93 | Yes |
| 3. Facilitate referrals to disease prevention and management services | 1.33 | 98 | Yes |
| 4. Support continuous availability of health services to clients | 1.28 | 98 | Yes |
| 5. Explain prevention and management actions for disease conditions prevalent in the community | 1.49 | 91 | Yes |
| 6. Explain health care payment mechanisms and procedures (e.g., Medicaid, Medicare, private insurance) | 1.86 | 76 | Yes |
Note. CHW = community health worker.
a Mean = central value of survey participants’ responses to a 5-point Likert-type scale rating the importance of each competency.
b 1 = extremely important and 2 = very important.
The community health workforce framework represents a continuum, as opposed to a hierarchy. It is not intended to create immutable divisions among CHWs, and in certain work settings, there may be overlap in job responsibilities. The framework illustrates how core competencies translate to different work settings and scopes of practice, highlights the role of CHWs in the continuum of care,27 and further elevates CHWs as health professionals.15 In practice, the framework is a useful tool for standardizing core and disease-specific competencies, standardizing terminology for describing scopes of practice, and directing training. It can also be used by managers to determine staffing needs. Although the expert panel eliminated a fourth proposed category from the framework because of a clinical scope of practice, extending the framework may be possible for a disease-specific continuum of care.
There was strong consensus among participants about the importance of the competencies (Table 2). The competencies with the lowest means in the set, and thus deemed to be the most important, were in community health practice (B6: advocate for clients’ needs) and diversity and inclusion (D3: function without judgment, bias, or stereotype). These rankings highlight the essential role CHWs play in representing clients and assisting them to access resources (B6) and the importance of how CHWs interact with and treat clients (D3). These 2 competencies also reflect how CHWs can build trust with medically underserved or vulnerable clients who may distrust health care systems.28
It is notable that all 4 assessment competencies had the highest means in the set, indicating that participants thought they were least important, though they still had mean rates well below 3. The most common critique of assessment, indicated by survey comments, was that it is outside a CHW’s scope of practice to have access to and apply data. Relatedly, a few participants stated that assessment competencies are only necessary for CHWs working in clinics. In writing these competencies, the term “data” was used to refer to any information from which conclusions can be drawn. Thus, regardless of workplace, CHWs should be able to use information to understand community health trends, participate in evaluation activities, track their activities, and document client interactions.4 Other CHW competency sets also include assessment as a necessary skill.12,29
However, CHWs who work in clinics likely have more need for data capabilities than CHWs working in nonclinical settings, particularly in terms of maintaining health records. Competencies should reflect how CHWs integrate into health systems,11 and the ability to use data and health information technology may facilitate integration in data-driven clinical environments.30 In hindsight, the wording of 2 of the assessment competencies (A3 and A4) may overly reflect clinical settings as they refer to “electronic medical records” and “clinic operations.” If these 2 competencies are used for training or evaluation in nonclinical settings, they can be rewritten as A3: “prepares reports using data,” and A4: “integrates findings of data assessment into organization’s operations.”
In the workplace, the competencies can be used to inform job descriptions, hiring and evaluating staff, and detecting knowledge and skills gaps within organizations.22 Because of the diversity of skills and knowledge in the competency set, employers may need to use several assessment methods to evaluate individual performance,31 such as 360-degree evaluations, observation of skills, and case logs.32 Assessments should be specific to workplace context and collected frequently.17 This study’s emphasis on writing competencies for measurable behavior will facilitate evaluation. Organizational factors that may impede a CHW from exhibiting competence should be also considered, such as limited resources, lack of coordination, and poor CHW integration.10 This adheres to the guideline to only assess competence independent of other individuals or external factors.19
Next steps for this work include developing curricula by using the competencies, expanding competency-based training opportunities for new and existing workforce members, and offering training that is accessible and convenient for many learners. Although it is preferable to develop competencies before curricula, existing training materials can be mapped to competencies.33 The CHW curricula currently utilized by many states and organizations could be adapted to this study’s competencies.
We recognize limitations to this study. Most survey participants lived in the South and were nonprofit employees. The sample may not be nationally representative and ideally would have had more even distribution of work settings. Also, other noteworthy competency efforts began after we completed our literature review in 2015 (see Rosenthal et al.29). In addition, development of competencies alone is not a guarantee of effective training or improved performance. CHWs have reported more confidence in their abilities after completing competency-based training, but more research is needed to examine how this type of training translates into effectiveness and job productivity.34 Finally, some essential CHW skills and knowledge may be enhanced by community membership or leadership. Experience-based factors like these do not lend themselves to competencies; rather, they should serve as minimum job qualifications and can be used to assess candidates for hire. Situating the study within a competency-based education approach, writing competencies for measurable behavior, and linking the competencies to a workforce framework are significant advances for CHW workforce development. Furthermore, engagement of an expert panel directly contributed to the competencies’ content validity, later verified by CHW professionals.
The effectiveness of public health programs and services is partially dependent upon workforce competency. The CHW core competencies and linked workforce framework are important for addressing health disparities and maximizing CHWs’ effectiveness.
ACKNOWLEDGMENTS
This study was supported by the Baton Rouge Area Foundation and the Gulf Region Health Outreach Program. The Gulf Region Health Outreach Program is funded from the Deepwater Horizon Medical Benefits Class Action Settlement approved by the US District Court in New Orleans, Louisiana, on January 11, 2013, and made effective on February 12, 2014.
We recognize and thank the members of the expert panel for their contributions. We also thank the staff members from the Center for Gulf Coast Environmental Health Research, Leadership, and Strategic Initiatives who assisted with the study.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
HUMAN PARTICIPANT PROTECTION
The Tulane University institutional review board determined this study to be exempt as it involved no more than minimal risk and approved a waiver of written informed consent.
