Special Issue, November 2005
COMMUNITY CASE STUDY
Texas’ Community Health Workforce: From State Health
Promotion Policy to Community-level Practice
Donna C. Nichols, MSEd, CHES, Cecilia Berrios, MA, Haroon Samar, MPH
Suggested citation for this article: Nichols DC, Berrios C, Samar H. Texas’
community health workforce: from state health promotion policy to
community-level practice. Prev Chronic Dis [serial online] 2005 Nov [date
cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/
Imagine yourself in Texas as a newly arrived immigrant who does not speak
English. What would you do if your child became ill? How would you find a
doctor? When you find one, will the doctor speak your native language or understand
your culture? In a state of
approximately 22 million people, many Texas residents, marginalized by poverty
and cultural traditions, find themselves in this situation. To help them, some
communities across Texas offer the services of promotores, or community
health workers, who provide health education and assist with navigating the
health care system.
In 1999, Texas became the first state in the nation to
recognize these workers and their contributions to keeping Texans healthy. This paper examines
a state health promotion policy that culminated in a
training and certification program for promotores and the impact of
this program on the lay health education workforce in Texas.
In 1999, the Texas legislature established the 15-member Promotor(a)
Program Development Committee to study issues involved in developing a
statewide training and certification program. During its 2-year term, the
committee met all six of its objectives toward establishing and maintaining a
promotor(a) certification program.
By the end of December 2005, it is estimated that there
will be more than 700 certified promotores in Texas. State
certification brings community health workers into the public health
mainstream as never before.
Promotores, a community health safety net and a natural
extension of the health and human services agencies, improve health at the
neighborhood level. Certification brings renewed commitment to serving others
and a distinction to those who have been the unsung heroes of public health
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There are about 30 different names for lay individuals who
provide community-level health services in the United States (1). In Texas,
these lay health educators are called promotores or community health
workers. The term promotores refers to lay health educators who
provide services in particular along the Texas–Mexico border; the term community
health worker (CHW) refers to lay health educators who practice anywhere
in Texas. Promotores or CHWs are often vital in linking underserved and
disenfranchised clients with essential health and human services. The
uniqueness of their service lies in their ability to relate to clients through
shared experiences drawn from living in the same communities. Firsthand
knowledge of the barriers that affect the health of a community gives CHWs a
stake in eliminating those barriers (2-5). Officially, Texas law defines a
or CHW as a person who, with or without compensation, provides cultural
mediation between communities and health and human services systems, informal
counseling and social support, and culturally and linguistically appropriate
health education; advocates for individual and community health needs; ensures
that people get the health services they need; builds individual and community
capacity; or provides referral and follow-up services (1).
The role of a promotor(a) or CHW differs widely from
community to community depending on the needs each community identifies. For
example, CHWs may serve as interpreters for clients during physician visits, help
clients identify benefits for which they are eligible, and assist them to
complete applications to receive benefits and services. As community
leaders, they may empower their neighbors by organizing and motivating them to
become actively involved in improving living conditions within their
neighborhood. In the role of health educators, CHWs may inform their clients
of ways to prevent illness and disease and teach them how to manage chronic
diseases. Experience has shown that CHWs are a valuable resource for informing
their neighbors and recruiting them to participate in social programs for which
In 1999, Texas became the first state in the nation to
legislate a statewide voluntary promotor(a)or CHW training and
certification program. As part of that legislation, the state established a
committee under the direction of the Texas Department of Health (TDH) to study
the feasibility and elements of such a program and make recommendations for
its implementation. This paper describes the work of this committee and the
resulting certification program for promotores and CHWs in Texas.
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The process of creating a statewide, state-supported training and
certification program for promotores and CHWs involved three groups.
First, in the mid-1990s, a series of meetings was held that brought together promotores
or CHWs, a CHW alliance, community leaders, health
professionals, and others interested in this public health work force from several southwestern border states. Second and also important were the promotor(a)
organizations, formed to provide communication and sharing networks among promotora
programs. One example is the South Texas Promotora Association, a loose federation of promotores
from 11 programs in the Lower Rio Grande Valley. One role of these
organizations was to advocate locally, regionally, and statewide for
recognition of their work. Third and finally, a group of state legislators,
all representing districts that form the border with Mexico, became catalysts for
creating a formal means through which to recognize and legitimize promotores’
work. All three of these groups helped to provide the context for the initial
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House Bill 1864, enacted by the 76th Texas Legislature in May
1999, directed the TDH to establish a temporary committee to make
recommendations on issues involved in the voluntary training and certification
of promotores or CHWs (4). From this directive, the
Development Committee (PPDC) was formed. The PPDC was composed of 15 members,
as provided for by the legislation: two promotores, two members of the
general public, two employees of the TDH, seven representatives of designated
colleges and universities in Texas, one representative of the Texas
Workforce Commission, and one representative of the Texas–Mexico Border
Health Services Delivery Project (7). The committee was charged with the
- Review and assess promotor(a) or CHW programs
currently in operation around the state;
- Study the feasibility of establishing a standardized
curriculum for promotores or CHWs;
- Study the options for certification of promotores or
CHWs and the settings in which certification may be appropriate;
- Assess available methods to evaluate the success of
or CHW programs;
- Create, oversee, and advise local pilot projects
established under this article, subject to the availability of
- Evaluate the feasibility of seeking a federal waiver so
that promotor(a) or CHW services may be included as a reimbursable
service provided under the state Medicaid program (7).
The PPDC met monthly for 2 years and submitted a
report on its activities after 1 year. The committee’s
work was completed in 2001.
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Program review and assessment
The first charge, to review and assess promotor(a) or
CHW programs currently in operation around Texas, required the PPDC members to
identify programs that train and employ promotores or CHWs within their
organizational networks. Using a Promotor(a) or CHW Workforce and
Training Questionnaire, the PPDC found approximately 30 existing programs using
some 300 promotores or CHWs as paid or unpaid, full-time or part-time staff.
Promotores or CHWs were serving in neighborhood clinics, local health
departments, community-based organizations, faith-based agencies, and
The second charge asked PPDC members to study the feasibility
of establishing a standardized curriculum for promotores
and CHWs. PPDC
members found that each existing training program uses its own curriculum,
which tends to focus on health specialties, organizational standards, and
other issues shaped by the needs of the community the program serves. These
curricula are as diverse in content and number of course hours as the programs
themselves. Consequently, a promotor(a) or CHW may be well trained to
work with the agency where training occurred but lack the skills required by a
different agency. Moreover, the differences in training can lead to
uncertainty as to what basic competencies potential employers can expect.
The PPDC reviewed state and national curricula and
decided that implementation of standard curriculum guidelines, which instill
portable skills, would ensure a common base of knowledge and guarantee certain
basic skills. This standardized curriculum focused on eight core areas of competence
- Interpersonal relations
- Capacity building
- Service coordination
These competencies are critical to accomplishing community health
improvement goals, including chronic disease prevention.
Minimum standard learner-centered objectives were created for
each competency. Stakeholder feedback was sought to make sure these objectives
were realistic and representative of promotor(a) or CHW
daily activities. With this the state is better able to ensure uniformity and
transferability of basic knowledge and skills regardless of where the
or CHW practices (8).
Public hearings were held in the cities of Arlington, El Paso, Houston, and Weslaco
on proposed rules for the certification of promotores or CHWs.
More than 150 individuals commented, with the majority being promotoras
or CHWs who participated in the public hearings. A diverse group of
organizational and political stakeholders were also represented, including
representatives from colleges and universities, government agencies, and
community health coalitions (2). The rules for certification adopted by the
Texas Board of Health in July 2000 are the result of the combined input of the TDH, the PPDC, and the many community members who participated in the process.
The rules serve as a blueprint for the training and certification program.
Among other qualifications, a minimum of 160 course hours must
be offered for a curriculum to qualify for certification. To be
grandfathered into certification, individuals must submit an application and
must have performed promotor(a) or CHW services
not fewer than 1000
cumulative hours from July 1997 to January 2004. This certification process
was based loosely on the professional certification process for health educators
known as the Certified Health Education Specialist and administered by The
National Commission for Health Education Credentialing, Inc.
Options and settings for certification
The third charge required the PPDC to study the options for
certification of promotores or CHWs and the settings in which
certification may be appropriate. The committee, with stakeholder feedback,
chose to certify promotores or CHWs, their instructors, and sponsoring
institutions or training programs. The rules specify qualifications and
special provisions for those who have historically been a part of the CHW
movement. Settings that are safe and comfortable and where learners feel
valued and respected were given primary consideration to support the special
needs of these adult learners.
Program evaluation methods
The fourth charge to the PPDC was to assess available methods to evaluate the
success of promotor(a) or CHW programs. Findings indicated that
programs use evaluation tools differently. Some programs evaluate processes and
others focus on outcomes. Some programs have used a combination of methods,
and some programs do not gather data at all or use data to evaluate their
efforts. The PPDC
agreed that as an overriding principle, programs should at least be able to
integrate an evaluation component that is adaptable for the varied
or CHW functions, including health, social services, education, or instruction.
Likewise, the ongoing evaluation of the program for practical purposes should
include the ability to assess curriculum, certification, training, and
programmatic implementation. In response to theses findings, the PPDC initially
recommended the use of a comprehensive, thoroughly field-tested evaluation
package known as the Community Health Worker Evaluation Tool Kit,
developed by the University of Arizona Rural Health Office and the College of
Public Health. The TDH (renamed The Texas Department of State Health Services
in September 2004) is in the initial phase of designing a tool to
evaluate program processes and outcomes.
The fifth charge to the PPDC was to create, oversee, and advise local pilot
projects established under this article, subject to the availability of
appropriations that may be used for this purpose. Five pilot sites were
selected by the TDH and Health and Human Services Commission (HHSC) committee
through a competitive process. However, because of shortfalls in general
revenue, the pilot sites were unfunded, which precluded the development of
neighborhood projects to test the feasibility of training, certifying, and
However, in late 2002, HHSC assisted the TDH with funding a neighborhood project
by seeking foundation resources to obtain additional federal Children’s Health
Insurance Program (CHIP) matching funds. In November 2002, Rockwell Fund, Inc awarded
$25,000 to Harris County Hospital District, Gateway to Care in Houston, and
this contract was executed in June 2003. The purpose of the pilot is to
test the effectiveness of CHWs in increasing access to primary and preventive
health care and reducing overall health care costs to the state. This project
received an additional award of $173,000 from the Houston Endowment for a
During the first 14 months of implementation of the Harris County pilot
project, 1017 CHIP and Medicaid families were served by receiving information
on and assistance with using health resources. Eight promotores or CHWs
and one instructor were certified by the TDH to work with Gateway to Care
families. In addition, Gateway to Care was approved by the TDH as a certified
Reimbursement of services from Medicaid
The sixth charge to the PPDC was to evaluate the feasibility of seeking a
federal waiver so that promotor(a) or CHW
services would be included as
reimbursable services provided under the state Medicaid program. The PPDC
recommended that all practical sources of funding within the state be
considered in supporting CHW services.
The PPDC recommended the following changes within the Medicaid system and
“right steps” for appropriate health and human services commission agencies
- Apply best practice models to eliminate barriers to care. These
included employing or empowering promotores
or CHWs to assist recipients in accessing Medicaid services, simplifying
Medicaid eligibility policies and procedures, reducing documentation
required by the application process, and requiring customer service and
cultural competency standards;
- Enable community residents to collaborate with health and human services
systems to build or tailor the Medicaid infrastructure to the unique
conditions of their environment;
- Promote independence and local control among community residents and
sustain commitment among health and human services agencies to improve
quality of life and eliminate health disparities.
Certification of promotores or CHWs in Texas
The PPDC accomplished its objectives in 2001 of preparing for a
promotor(a) training and certification program. In that same year, the Texas
legislature passed two pieces of legislation related to promotor(a) certification. Senate
Bill 1051 mandated that all promotores or CHWs who receive compensation
for their services be certified. Previously, the certification process was
voluntary for all promotores or CHWs. The second piece of legislation,
Senate Bill 751, required that state health and human services agencies use
certified promotores to the extent possible for recipients of medical
assistance. Together, these mandates increased the immediate need for approved
training programs and a standardized certification process.
Promotor(a) or CHW Training and Certification Advisory Committee
To oversee the certification process, the Texas Promotor(a) or CHW
Training and Certification Advisory Committee was established in 2001. This committee,
reporting to the TDH, determines the eligibility of and recommends certification for promotores
or CHWs, instructors, and sponsoring institutions or training programs.
The Promotor(a) or CHW Training and Certification Advisory Committee is
composed of nine members approved by the Texas Health and Human Services
Commission. (Prior to September 1, 2004, members were approved by the former Texas
Board of Health.) The committee includes four certified
promotores, CHWs, or the equivalent; two members of the public; one member from the Texas
Higher Education Coordinating Board or a higher education faculty member who has
teaching experience in community health, public health, or adult education and
has trained promotores or CHWs; and two professionals who work with promotores
or CHWs in a community setting (2).
By December 2002, the committee had developed, field tested, and finalized
the certification application form for promotores or CHWs. Six
certifications were conferred at an official ceremony at the 2002 CHW state conference, and the
committee conducted several promotional
workshops to distribute certification applications and instructions (available
from www.tdh.state.tx.us/ophp/chw/chwdocs.htm*). By December 2003, a database
for tracking the review and disposition of applications for all three forms of
certification and recertification was implemented; 224 certifications for promotores
or CHWs were conferred; certification IDs were accepted as proof of
qualifications by all organizations in Texas; certification renewal forms were
created; and a Web site for the Texas Promotor(a) or CHW Training and
Certification Advisory Committee was launched. By December 2004, the
committee had certified 337 promotores or CHWs,
24 instructors, and 3 training programs. By the end of December 2005, it is estimated that
there will be more than 700 certified promotores or CHWs in Texas.
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The impact of the training and certification program on CHWs is deeply
personal. CHWs provide a number of reasons for seeking certification:
self-development, recognition by others of their position and work,
professional enhancement, new incentives to work, and the possibility for
career development (6). In addition, certification of CHWs provides
credibility, recognition, and the development of scope of practice.
Counterarguments are made by CHWs who wish to function on a
volunteer basis or by individuals who are concerned that certification of CHWs
will erode the professional base of another regulated, licensed, or certified
professional group. There are many people who feel that professionalizing CHWs
will result in a loss of the indigenous qualities that contribute to their
success. However, CHWs may continue to volunteer their services without
penalty; CHWs who provide services without compensation are not required to be
CHWs in Texas, for the most part, work in an integrated fashion within the
health and human services system and seldom work with a specific “carve-out”
or solely funded CHW program. Therefore, sustainability of CHW programs may
not be a major issue for Texas. As with all federally funded or state or
locally funded programs, sustainability is an issue regardless of the types of
individuals providing services to their communities. Institutions are at a
greater legal risk if their CHWs are not certified, because many
of these workers visit clients in their homes and are at greater personal risk if
they cannot visibly and legitimately identify themselves with an organization. CHWs in Texas are just beginning to receive compensation
for their services through various sources. For example, certified CHWs have
been employed by Maximus, Texas’ Medicaid enrollment broker, to conduct the
outreach necessary to inform Medicaid enrollees of their benefits.
There is no application fee associated with certification. Costs, if any,
are borne by the employer or the CHW for training or recertification, which
may include a cost for continuing education. To date, cost has not been
an issue. The greater issue in the future is anticipated to be access to and
availability of continuing education for CHWs. The time needed for training
has not proven to be a barrier to certification, either. CHWs who wish to
improve their skills and knowledge, regardless of certification status, will
have the opportunity to do so through certified training programs.
The greatest challenge to implementing the CHW training and certification
program was working with a diverse, vocal, and broad-based committee that
represented academic systems, state agencies, the general public, and CHWs in creating a shared vision and a unified set of
recommendations on how this training and certification program should
function. Staff worked diligently to ensure that the voice of the CHW was
heard throughout the process and established a public comment period as a
standard procedure for each official meeting and hearing conducted by the TDH.
Since the rollout of the certification application for promotores
or CHWs in December 2002, there has been much interest in the certification
program statewide. Program staff respond to approximately 120 inquiries per
month about certification policies and procedures. As of May 2005, the Texas
Department of State Health Services had certified 500 promotores, 24
instructors, and 6 sponsoring institutions or training programs in Texas. Two
additional training programs were certified in June 2005
(Table). A map
showing the number of certified promotores in each Texas county is
available from www.tdh.state.tx.us/ophp/chw/pubs/promotorasmay05.pdf*.
For the first time, Texas has recognized the power and the value of this
community health safety net by giving long overdue recognition to the health
education workforce that has worked silently and tirelessly to
keep their communities healthy and fit.
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Corresponding Author: Donna C. Nichols, MSEd, CHES, Senior Prevention
Policy Analyst, Center for Policy and Innovation, Texas Department of State
Health Services, 1100 West 49th Street, Austin, TX 78756. Telephone:
512-458-7375. E-mail: email@example.com. Ms. Nichols was
previously Director of Health Promotion at the Texas Department of Health and
the staff director for ensuring implementation of the lay health education
workforce statute in Texas.
Author Affiliations: Cecilia Berrios, MA, Haroon Samar, MPH, Texas
Department of State Health Services, Austin, Tex.
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- Texas Department of State Health Services. Report on the feasibility of voluntary
training and certification of promotores(as) or community health workers.
Austin (TX): Texas Department of State Health Services; 2001.
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University of Arizona, Mel and Enid Zuckerman Arizona College of Public
Health; 1998 Jun [cited 2005 Mar
16]. Available from: URL: http://www.rho.arizona.edu/nchas_files/nchas_summary.htm*.
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California. San Francisco (CA): California Workforce Initiative, UCSF for
the Health Professions; 2004 Sep.
- Meister JS, Guernsey de Zapien J.
Bringing health policy issues front and center in the community: expanding
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- Swider SM.
Outcome effectiveness of community health workers: an
integrative literature review. Pub Health Nurs 2002 Jan-Feb;19(1):11-20.
- May M. Certification of community workers: a Texas case study
(draft). Bryan (TX): Texas A&M University Health Science Center, School of Rural
Public Health; 2004 Nov-Dec.
- Texas Legislature Online. House Bill 1864, enrolled version.
Austin (TX): Texas Legislative Council [cited 2005 Jul 25]. Available from:
URL: http://www.capitol.state.tx.us/cgibin/tlo/textframe.cmd? LEG=76&SESS=R&CHAMBER=H&BILLTYPE=B
- Texas Department of State Health Services. Promotora Program Development Committee
minutes. Austin (TX): Texas Department of State Health Services; Oct 1999–Nov 2000.
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