Focus on the Future: A Community Health Worker Research Agenda by and for the Field

Abstract

Research articles describing community health worker (CHW) programs often focus on program activities and short-term outcomes, failing to assess CHWs' long-term contributions to improving individual and community health. Reflecting this, CHWs are supported by short-term public and private funding.
To inform policies that will potentially increase support and funding for CHW work, specific research is needed providing evidence of CHW effectiveness. This article describes the development of a CHW research agenda by and for the field.
CHWs, researchers, and stakeholders (policy makers, funders, others) collaborated during and after a conference to develop and refine a 164 question agenda targeting six areas (Table 1).
Key research areas identified by the agenda development participants include: * CHW impact on health status; * CHW cost effectiveness; * Building CHW capacity and sustaining CHWs on the job; * Funding options; * CHWs as capacity builders; and * CHWs promoting real access to care.

Full text

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pchp.press.jhu.edu © 2008 The Johns Hopkins University Press
POLICY AND PRACTICE
Focus on the Future: A Community Health Worker Research Agenda by
and for the Field
E. Lee Rosenthal, PhD, MPH1, Hendrik de Heer1, Carl H. Rush2, and Lisa- Renee Holderby3
(1) University of Texas at El Paso, College of Health Sciences; (2) Community Health Resources, LLC; (3) Massachusetts Association of Community Health Workers
Submitted 31 December 2007; revised 8 April 2008; accepted 5 May 2008.
I
ndividuals functioning as natural helpers have always
been present in communities. They have provided social
support, given advice on treatment of illnesses, and
offered specific skills such as midwifery.
1,2
Individuals serving
in a natural helper role, both in paid and volunteer positions,
have come to be known as CHWs. In the literature, CHWs
have been described as community members who carry out
a range of roles and activities including that promote health
and improve access to care. There were seven roles reported
in the National Community Health Advisor Study3,4:
1. Cultural mediation
2. Health education
3. Ensuring access to care
Abstract
Problem: Research articles describing community health
worker (CHW) programs often focus on program activities
and short-term outcomes, failing to assess CHWs’ long-term
contributions improving individual and community health.
Reflecting this, CHWs are supported by short-term public
and private funding.
Purpose: To inform policies that will potentially increase
support and funding for CHW work, specific research is
needed providing evidence of CHW effectiveness. This article
describes the development of a CHW research agenda by and
for the field.
Key Points: CHWs, researchers, and stakeholders (policy
makers, funders, others) collaborated during and after a
conference to develop and refine a 164 question agenda
targeting six areas (Table 1).
Conclusions: Key research areas identified by the agenda
development participants include:
• CHWimpactonhealthstatus;
• CHWcosteffectiveness;
• BuildingCHWcapacityandsustainingCHWsonthejob;
• Fundingoptions;
• CHWsascapacitybuilders;and
• CHWspromotingrealaccesstocare.
Keywords
Community-based participatory research, community health
research, health promotion, health care quality, access, and
evaluation, health services accessibility, delivery of health
care, community health services
4. Informal counseling and social support
5. Individual and community advocacy
6. Provision of direct service
7. Individual and community capacity building
Beginning in the mid-1990s,5,6 the field has received sig-
nificant national attention highlighting CHWs’ important role
in addressing health disparities and health access throughout
the United States. As part of this growth, research exploring
the CHW model has also increased.4 Nonetheless, questions
remain about definitive documentation of CHWs’ effective-
ness.
7,8
Also reflecting increased interest in the CHW approach,
policy steps toward sustainability of CHWs have been made.i
Still, to date, there are no encompassing national policies
supporting the integration of CHWs into the health and

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Progress in Community Hea lth Partnerships: Resea rch, Education, and Action Fall 2008 • vol 2.3
human services system leading to routine reimbursement of
CHW services.
4,5,9–11
Despite the popularity of the CHW
approach, funders, researchers, and practitioners alike call for
stronger research exploring both process and outcomes
measures.
Several challenges exist in evaluating and researching
CHW programs. Responsive community programming and
significant variation in CHW roles and training
6,12
complicate
evaluation processes and limit the ability to draw conclusions
across multiple sites. Additionally, CHW research is chal-
lenged by limited, short-term funding confounding the ability
to measure long-term effects.13
The present article covers findings from a participatory
process where CHWs, researchers, and funders, along with
other stakeholders,
ii
worked together to address these chal-
lenges. The primary objective of this paper is to introduce
readers to the first outcome of these efforts: a newly developed
CHW research agenda outlining issues related to both process
and outcomes research. The agenda aims to guide future
research to overcome the challenges briefly outlined. The
article also describes the participatory methodology used to
develop this agenda to show the important participant con-
tributions and buy-in reflected in the proposed agenda.
Exploring CHWs’ role in research is a natural extension of
assessing CHW field research needs. Therefore, this article
also briefly examines this topic.
A RESEARCH AGENDA “BY THE FIELD”
Given the current state of reported CHW research, a group
of CHWs, researchers, and stakeholders took steps to generate
a CHW research agenda created by and for the field. This
stakeholder group included funders, payers, and others sup-
porting research and service delivery by CHWs. The catalysts
for this effort were individuals active in the leadership of the
American Public Health Association (APHA) CHW Special
Primary Interest Group (SPIG), although the CHW SPIG was
not a sponsor of the agenda-setting process. The multidisci-
plinary approach to agenda development had a community-
based participatory research approach embedded within it,
focusing in this case on drawing together a community of
interest that was national in scope. Planners embraced an
approach of inclusion that builds on the “guiding principles”
of campus–community partnerships.14
Why Develop a CHW Research Agenda by and for the CHW
Field?
The January 2007 2-day invitational conference, “Focus
on the Future: Building a National Research Agenda for the
Community Health Worker Field,” built on previous efforts
in the CHW field
4,13
to bring CHWs and others together to
self-define research, practice, and policy issues confronting
the field. The invited participants collaboratively engaged in
a consensus-building process to develop a CHW research
agenda. This effort supplemented and built on a CHW research
agenda
iii
developed for the field by the Office of Minority
Health as part of a larger research agenda on cultural
competence.15
An underlying belief among conference organizers16 was
that, to stimulate policy change to support the work of CHWs,
research is needed to inform policy. Planners determined that
policy makers should play an active role in shaping the research
agenda to ensure that future research meets their perceived
needs for information. Such research can fill evidence gaps,
especially in areas that are important in policy decision mak-
ing, such as cost effectiveness. Findings from such research
will be valuable when “policy windows” open,
17
providing
needed data to support policy discussions regarding CHW
funding.
DEVELOPING A CHW RESEARCH AGENDA
The Process of Setting the Agenda
To develop the CHW research agenda, funding was solic-
ited from several sponsors. The planning group and the agenda
development process were staffed by a Texas-based CHW-
focused consulting group, which also contributed from its
own resources. Early in the outreach process, The California
Endowment committed seed monies for staffing and direct
conference expenses, challenging the organizers to find match-
ing funds. In addition, four private and two public (see
Acknowledgements) funding sources were successfully solic-
ited to sponsor the conference and the overall research agenda
development process; additionally, all but one of the confer-
ence funders sent participants to the conference.
The five major steps in the agenda setting process were
(1) gathering resources and representative advisors from the

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Rosenthal et al. Community Health Worker Research Agenda
community of interest, (2) gathering background information
and planning for the agenda drafting process (primarily
through a conference), (3) holding the agenda drafting confer-
ence, (4) refining and validating the initially proposed research
agenda, and (5) collaboratively disseminating the research
agenda.
Gathering the Community of Interest. Planning committee
formation came through a self-nomination process among
individuals within the leadership of the APHA CHW SPIG.
The group sought to be inclusive, allowing for new members
to join as interest increased. It was determined that the meet-
ing would be an invitational meeting with a diverse representa-
tive group of participants. To maximize the credibility of the
proposed research agenda by funders and policy makers, it
was agreed (with some hesitance by planners) that CHWs
themselves should represent a smaller percent of the total
conference participants. Also, a rationale was that the research
agenda should especially attend to the questions that funders
and policy makers feel they need to answer to make policy
decisions. Nonetheless, all planning group members agreed
that all groups should be represented at the meeting by strong
voices. To develop the invitee list, a subcommittee took the
lead with all planners contributing names.
iv
Ultimately, more
than 70 conference participants represented organizations
from 20 states and Washington, D.C. Three quarters of par-
ticipants were female, and the group was culturally diverse
with less than half being non-Hispanic White. One fifth of
participants were CHW leaders. Over half of the participants
identified themselves as being representative of the private
sector (including community-based organizations).
The Conference Planning Process. The planning committee
prepared preconference materials including a summary of
nine recent U.S. CHW literature reviews.
18
The planning group
determined that, to ensure credibility of the research agenda,
the agenda-setting process should not presume the efficacy
of the CHW model, but should instead acknowledge ongoing
debate.
The conference planning committee generated a list of 11
broad topic areas in need of further research in the CHW field
through a consensus-driven dialogue. Topic areas identified
covered many areas:
1. CHW impact on health status
2. CHWs promoting real access to care
3. CHWs as community capacity builders
4. CHW cost effectiveness or return on investment
5. CHW key roles and characteristics
6. Options for funding CHW services
7. Quality of CHW services
8. Demand for CHWs
No figures were provided.
Figure 1: Shows Topic Areas by total points assigned in a ranking process conducted in pre-conference voting.

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9. Visibility and integration of CHWs as an occupational
group
10. CHWs versus other professions
11. Building CHW capacity and sustaining CHWs on the
job
12. Other topics: any other issues that are in need of
research
This list was not intended as prescriptive, but was offered
as a starting point for identifying critical research areas to be
explored at the conference. Before the meeting, participants
received an e-mail ballot featuring the broad topics. They were
asked to rank their top five topics, including any new topic,
assigning five points to their top pick, four to the next, and
so on. Late ballots including hard copy format were accepted
at conference and tallied on site. Rankings were analyzed by
the conference staff and shared at the opening in a Power
Point presentation. Findings were portrayed in two formats
with a ranking of the (1) most total points and (2) those topics
receiving the “most high ranks” (ranked either a 4 or 5 with
5 the highest rank; Figures 1 and 2). The scale listing the “most
high ranks” was designated as the “passion index.” The most
total points ranking served as the basis for designating small
group discussion topics on day 1.
An important decision of the planning committee was to
embrace a common CHW definition. The CHW definition
selected was prepared by members of the Executive Committee
of the APHA CHW SPIG and was sent to participants before
the conference. That definition read as follows:
A Community Health Worker (CHW) is 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 CHW 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 CHW 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.v
The Agenda Drafting Conference: Focus on the Future.
During the conference, the three primary participant groups
(CHWs, researchers, and stakeholders) were referred to as
“affinity” groups. At certain points within the agenda develop-
ment process, affinity groups were asked to work indepen-
dently from the other affinity groups. For example, CHWs
were asked to work together with other CHWs in small groups.
Figure 2: Shows Topic Areas by number of participants ranking each Topic Area as either a 4 or 5
in pre-conference voting with 5 as the highest rank.
No figures were provided.

229
Rosenthal et al. Community Health Worker Research Agenda
In other instances, members of several affinity groups worked
in interdisciplinary groups (e.g., CHWs, researchers, and
stakeholders). Steps were taken to ensure participation of
CHWs. For example, CHWs were invited to comment first
during selected conference discussions and time was desig-
nated for CHWs to voice their perspective on the progress of
the agenda development.
Brainstorming groups at the conference were organized
around the top six research topics identified by the preconfer-
ence voting and one group covering “all other topics.” The
topics in order of preference based on the pre-conference
voting (Figure 1) were:
• CHWimpactonhealthstatus
• CHWcosteffectiveness/returnoninvestment
• BuildingCHWcapacityandsustainingCHWsonthejob
• Fundingoptions
• CHWsascapacitybuilders
• CHWspromotingrealaccesstocare
Brainstorming sessions were based on open space technol-
ogy,
19
which allowed for continuous flow of individuals
between groups. In open space technology sessions,19 the
conference room is set up as a “marketplace for ideas.”
Participants attend and leave discussion groups at will. In such
a conference, “The Law of Two Feet” rules indicating that:
“…in a situation where you aren’t learning or contributing,
go somewhere else.” Three rounds of discussion generated
164 questions for the research agenda
20
(Table 1). Conference
participants voted on these individual research questions.
These were tallied and subtotaled by the three affinity groups.
Participants discussed the vote and explored conditions neces-
sary to make the identified questions researchable. Beyond
the six major themes, a number of methodological questions
were raised and documented that did not fall into these
categories.
Participant Commitments. After confirmation of the
groups’ priority research areas, participants formally devel-
oped individual and agency “Commitments” (or Compromisos
as they were called in this Texas-based meeting) that they
planned to undertake to aid implementation of the proposed
CHW research agenda. Participants provided details for their
Commitments on a worksheet that included a timeline and
potential stakeholders. Numerous individuals publicly
expressed their Commitments. Examples included such ideas
as a peer-reviewed journal for and by CHWs, a fact sheet on
CHWs for all state legislatures, and a public health journal
supplement on CHW research.vi
Refining the CHW Research Agenda. At the conclusion of
the conference, a Communication Committee was formed,
including CHWs, to lead the next phase of agenda refinement.
As a part of this follow-up phase, conference findings were
e-mailed and affinity and “all-comer” town hall–style confer-
ence calls were held to review the agenda. Furthermore,
individual follow-up calls were made to all CHW conference
participants.
After the conference participant review, comments on the
research agenda were solicited from all identified national,
state, and local CHW networks/associations in the United
States, as well as other experts and opinion leaders in the CHW
field. To identify these groups, outreach was conducted to
locate CHW organizations in all 50 states. Ultimately, 4
national CHW organizations, 11 statewide organizations, and
5 local level organizations were contacted by phone. All con-
firmed contact persons were sent an electronic version of the
research agenda and were asked to distribute it to the organiza-
tions’ leadership team and members for feedback. Follow-up
calls and e-mails have been made to the contact person of
each organization.
To date, 4 of 20 organizations responded to the request
for feedback; notably, approximately half of the 20 had rep-
resentatives at the agenda-setting meeting. Of the groups that
did not respond, several identified that they had been unable
to meet in the designated time frame of 1 month.vii Although
the feedback was somewhat limited, it was evident that the
CHWs contacted were interested in participating to some
degree. Overall, feedback was favorable to both the concept
of a national research agenda and desire for continued CHW
input to the process. In all cases, the point person for the CHW
organizations were encouraged to offer feedback at anytime,
as the research agenda is a living document.
Collaborative Dissemination. The final agenda and sup-
porting documents of the participatory process are being
released through multiple channels including conferences and
articles. Specifically:
• Atthe2007APHAmeeting,severaleventshighlighted
the CHW research agenda. An agenda release reception

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Table 1: Community Health Worker Research Agenda: Generated Research Questions
Community Health Worker Research Agenda: Generated Research Questions (summarized)
Researchers
Other
Stakeholders
CHWs
Total Average
1. CHW Impact on Health Status 5 1 1-tie 2*
What is the impact of different types of CHW interventions on health outcomes (physical, psychological,
social) and disparities?** 23% 27% 30% 27%***
What is the impact of CHW activities on INTERMEDIATE outcomes on the individual and community levels
(social and medical determinants of health, access to health care, quality of care, system reform)? 30% 22% 15% 22%
What process takes place between a CHW and the person with whom he/she works that results in change? Is
this process/ capability inherent in the attributes of one who becomes a CHW, or can it be learned? 12% 14% 21% 16%
2. CHW Cost-Effectiveness /Return on Investment (ROI) 4 2 1-tie 1
How do services (including prevention) provided by CHWs impact health care costs short- and long-term? 39% 44% 20% 37%
What is the cost-effectiveness of interventions involving CHWs compared to similar interventions which do
NOT involve CHWs? 13% 16% 13% 15%
What is the cost effectiveness of CHWS in reducing missed appointments? 16% 9% 17% 13%
What are the direct and indirect economic contributions of CHWs (cost control, revenue enhancement,
multiplier effects in community economic development, improving client economic status, etc.)? 10% 10% 27% 14%
Do benefits/incentives affect CHW effectiveness, work performance? 9% 11% 10% 10%
[ADDED in review] What is the optimal ratio of CHW staffing to size of population served for various CHW
functions?
3. Building CHW Capacity and Sustaining CHWs on the Job 1 4 3 3
What are the skills and competencies that describe the CHWs’ functions and scope of practice? 46% 55% 34% 46%
What is the value added of CHWs to the public health workforce, and how do we link this to ongoing efforts
to improve the public health workforce?
25% 27% 29% 27%
What are the most successful training methods for CHWs? 8% 15% 14% 13%
[ADDED in review] What are trends in career patterns and job security of CHWs? How do they differ between ongoing programs and shorter-
term projects?
4. Funding Options [all are policy/advocacy issues suited for policy studies] 2 6 5 4
What are the most promising models for sustainable funding of CHWs that can be replicated? What are
barriers to their adoption? What information do funders/policymakers need to implement such models?
58% 51% 61% 57%
What are opportunities and barriers for reimbursement of CHW services through Medicaid? What
mechanisms (waivers, State plan amendments, etc.) are available in individual states?
29% 31% 27% 29%
[ADDED IN REVIEW] What is the demand for CHWs?
table continues
* Participants voted with dots both for Topics Areas (1-6) and for individual questions. Votes for Topic Areas are presented here in rank order (the highest rank is
given to the topic area receiving the largest number of votes) by participant category (affinity group) and by total average rank.
** In some cases questions presented here were collapsed into broader questions; the questions’ percentages were then added together for presentation in this table.
*** Percentages represent the total percentage of the votes cast by each participant category (affinity group) within a Topic Area for the presented questions.
Questions not receiving 10% of the vote from any group are not presented in the table. Due to this, percentages by Topic Area may not sum to 100%.

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Rosenthal et al. Community Health Worker Research Agenda
Table 1 continued: Community Health Worker Research Agenda: Generated Research Questions
Community Health Worker Research Agenda: Generated Research Questions (summarized)
Researchers
Other
Stakeholders
CHWs
Total Average
5. CHWs as Community Capacity Builders 3 3 4 5
What are the core competencies of a CHW as a community capacity builder? 53% 37% 45% 44%
What methods do CHWs use to engage residents, institutions and other partners in the community in an
effort to build capacity?
28% 41% 42% 38%
How does community capacity-building benefit the different sectors of society (private sector, hospitals,
public health services, economy)?
11% 20% 10% 14%
6. CHWs Promoting Real Access to Care 6 5 6 6
How effective are CHWs in promoting access to health and social services? 52% 35% 50% 45%
Are CHWs who receive disease-specific training better at improving access than CHWs with more general
training?
9% 15% 27% 16%
What infrastructure needs to be in place for CHWs to address access to care? 9% 20% 7% 12%
Does including CHWs in the education of health professionals (curriculum content ABOUT CHWs and/or
CHWs as teachers) improve access and quality of health care services?
11% 17% 0% 10%
[added in review] What training is needed for CHWs who are asked to serve as interpreters in medical and other encounters?
NOTE: the remaining questions were removed from their original Topic Areas during the review process and are ranked within the categories shown.
Methodology questions
What is an appropriate new paradigm for CHW research studies (incorporating spiritual, physical,
emotional, human rights, community justice elements) overcome the weakness of “traditional” designs
such as medical-model intervention studies in capturing the effects of CHW activity?
20% 16% 35% 25%
How do you isolate the intervention of the CHW from all of the other pieces of the intervention (primary
care, specialists, etc.) to identify the effect of the CHWs’ work?
15% 36% 19% 22%
What standard criteria should be used for the “base case” (status quo or non-CHW intervention) to compare
to a CHW evaluation/intervention?
10% 8% 19% 13%
What are the best measures of the client/patient, provider/supervisor expectations placed on CHWs, and of
client/patient, provider/supervisor satisfaction with CHW services?
15% 16% 8% 12%
What are appropriate measures of success for CHW work vs. program goals? 18% 16% 0% 10%
Other policy/advocacy issues (potential policy studies)
What infrastructure/support systems (e.g. employers, trainings, resources, etc.) need to be in place in order
for CHWs to function to their full capacity in the community?
28% 33% 17% 25%
What funding models are appropriate to support CHWs in promoting social justice in their communities? 20% 25% 11% 18%
What are the possible models for organizing the CHW field? What is the best leadership structure to
advocate for the field? How can this structure be funded?
20% 8% 23% 17%
How can CHWs be better integrated into the healthcare system? 13% 13% 9% 11%
Adapted from a table developed by Community Resources, LLC.
This table presents findings from a voting process undertaken at the meeting utilized to evaluate the relative importance of questions generated by meeting
participants. Specifically, conference participants produced 164 research questions on day one of the meeting. On day two, participants voted to prioritize the list of
questions through the use of color coded dots assigned by affinity group (CHWs; researchers; and funders/stakeholders.)

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was coordinated by the CHW SPIG. The Community
Health Planning and Policy Development Section of
APHA invited the CHW SPIG to organize a special
session on CHW research and policy, which featured
several participants from the research agenda
conference.
• TheNationalConferenceofStateLegislaturesisinthe
process of sending a fact sheet to all state legislatures
and a complete policy review of the CHW field to state
legislative health committees throughout the country.
Already at a meeting of the National Conference of
State Legislatures, CHW field developments have been
presented, including highlights from the draft CHW
research agenda.
• Articlesandotherpublicationsbyconferencestaffand
participants, including CHWs, are part of the dissemi-
nation strategy, which to some degree was developed
through the project’s Commitment process, this article
among them.
CHWS ROLE IN RESEARCH AS PARTNERS AND CATALYSTS OF
THEORETICAL DEVELOPMENT
Giving direction to CHW research was a mission of the
participatory process described. This article now shifts to a
discussion of CHWs’ role in research as an emerging role of
potential importance in the future. It seems that the CHW
role in research may have strong roots. In the past decade,
attention increased for CHWs as an integral part of the public
health workforce.
4,5
A new CHW role that is emerging is
CHWs’ as partners in research.6,21,22 CHWs have often found
themselves to be integral contributors in intervention
research.7,23 While carrying out their usual roles, researchers
and evaluators analyze the impacts of CHW and interventions
on individuals, families, and communities. Through this
effort, it is hypothesized that CHWs may have contributed to
the development of health and behavior theories that are part
of current mainstream research and practice.
viii
However,
specifics of how CHW service may have influenced theories
of change relating to health and health care utilization have
not been sufficiently documented.
CHW roles such as social support have been identified in
major sociology and social psychology theories that include
the Health Belief Model
24,25
and Social Learning Theory.
26
Such
theoretical perspectives were all strongly influenced by Kurt
Lewin’s work on social interaction, conflict resolution, leader-
ship, and interdependence.27 This supports applied research
and building bridges between theory and the reality of the
individual case. It seems likely that CHWs’ long history of
connecting health and human service providers to those they
seek to serve has also fostered linking researchers to com-
munity members in some cases contributing to theory
building.
DISCUSSION OF LESSONS LEARNED
There are several lessons learned from the development
of a CHW research agenda. Those insights are now reviewed
through a discussion of lessons learned in agenda development,
exploring CHWs’ role in research, and examination of the
content of the research agenda itself.
Lessons Learned in Research Agenda Development
The research agenda-setting process led to a number of
insights about participatory methods. Inviting three different
stakeholder groups resulted in very rich discussions and
presentation of different viewpoints. The groups’ diverse
backgrounds provided a base for discussion closely related to
challenges experienced in the CHW field. By making formal
individual Commitments, each participant expressed owner-
ship of the development of a research agenda and had a clear
direction for their own individual participation. This approach
added value to the agenda-setting process by formalizing
implementation steps that could be taken by participants.
Developing a research agenda by and for the field where input
from all involved parties is solicited seems to have set the stage
for future research agenda implementation. The grounding
in community-based participatory methods was vital in creat-
ing this momentum.
28
This approach fosters participant
action, even on a national scale, as evidenced by collaborative
agenda dissemination and action on individual Commitments
now underway.
Beyond the process lessons learned, starting a dialogue on
CHW research brought forward several research issues that
have not been fully explored and documented. The conference
became a platform for that dialogue. Although it was recog-
nized as an important opportunity, it was inadequate for that
purpose. The amount of time devoted to these issues (see
discussion on Shaping the Content, below) complicated mak-

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Rosenthal et al. Community Health Worker Research Agenda
ing as much progress on drafting a research agenda as confer-
ence planners intended.
A related significant dialogue unfolded with regard to
research and policy goals. Participants cautioned against only
selecting research questions based on policy relevance. The
group discussed how policy research may fail to address
important issues to the CHW field itself in terms of refining
CHW program models. Nonetheless, the group acknowledged
the importance of looking for opportunities to link research
findings to policy.
The research agenda-setting process also revealed specific
challenges. First, the status of the intended product of the
conference and related processes was ambiguous to partici-
pants. Planners should have made it clearer that the conference
product was a proposed draft for discussion and not a final
document. Further, the term “research agenda” itself may
have required additional clarification to promote greater
understanding among all present. Voting for research topics
and research questions to build consensus versus a more
interactive consensus-building process approach posed chal-
lenges despite a user-friendly voting approaches. Also, a fol-
low-up phase dependent on conference calls and e-mails
makes reaching consensus difficult and to some degree, dif-
ficult to discern.6,12 Another important contributor to chal-
lenges in the process was the lack of an equal number of CHW
participants. This limitation seemed to have raised tensions
at the conference and in the follow-up phase, especially among
CHW participants. Participants, CHWs in particular, were
concerned that their voices be blended with other groups,
preferring instead at times to have their independent perspec-
tives heard and documented. Finally, in undertaking
Commitments, it was clear that individual commitments were
far more realistic than agency-level commitments.
Lessons Learned in CHWs Role in Health Research
This article briefly examines CHW roles in research. Early
findings in this area suggest that further research is needed to
reveal the unique, hands-on role that CHWs have played in
the past and to provide insights into the nature of potential
CHW research roles in the future. The research agenda itself
developed at the conference upholds this recommendation.
Lessons Learned in Shaping the Content of a CHW Research
Agenda
Exploration of the research agenda itself brought to light
several issues about research processes and field development
issues. Two broad research challenges were identified. First,
participants suggested that future research findings need to
better document CHW program characteristics through
inclusion of such details as a description of CHW capacity
building/education, CHW roles, and payment mechanisms.
A second and equally important challenge was related to
comparability of CHW programmatic outcomes. Some
participants identified that using common measures of
outcomes would increase comparability of findings and the
strength of results that can be shared. Also, in the authors’
perspective, such metrics may anticipate potential growth in
the field and allow for proactive establishment of standards
by the field for the field. Such measures may also later be
utilized as performance standards by entities reimbursing
CHW services. Participant discussion of the need for this
ultimately led to planning for a second, similar conference
process that will identify and formally propose those key
metrics.
Other research issues raised included concern that the
traditional medical model of outcomes research was not in
all cases a valid model for evaluating CHWs’ community-
responsive and diverse contributions. Some were concerned
that recommended cost–benefit assessments might be inap-
propriate methods to assess the worth of CHWs. Also, an
overall interest was expressed in building theoretical constructs
to the applications of the CHW model in addressing health
disparities (i.e., racial, ethnic).
CONCLUSIONS
The overall experiences in this multidisciplinary collabora-
tive for CHW research were positive. Opportunities to interact
with different affinity groups before conducting research may
be valuable for development of research questions of special
relevance to CHWs and communities they serve. The agenda
20
(Table 1) provides a compass for the CHW field and other
stakeholders, and can lead to a multifaceted approach to filling
the gaps in knowledge about the process and outcomes of
implementing and sustaining CHW programs in the United

234
Progress in Community Hea lth Partnerships: Resea rch, Education, and Action Fall 2008 • vol 2.3
States. Each of the areas identified responds to the needs of
varied audiences. The participants identified that progress in
all research areas is critical to advance the CHW field. In
conclusion, CHWs’ role in promoting health and access to
care is carried out daily in communities, and the research
community is invited to work to better document and illumine
those roles in partnership with CHWs.
Acknowledgments
The authors wish to acknowledge Community Health
Workers for their ongoing efforts to serve their communities
and promote health equity. The authors would also like to
acknowledge the participants and staff who took part in the
“Focus on the Future” conference and research agenda refine-
ment. Furthermore, we would like to acknowledge the valuable
contributions and encouragement of funders who supported
the endeavor, including The California Endowment; Northwest
Area Foundation; California Health Care Foundation; The
California Wellness Foundation; Pfizer Health Solutions;
Health Education Training Centers Alliance of Texas
(HETCAT); Health Care Education–Industry Partnership,
Minnesota State Colleges; and to the Universities Fiscal Agent
for Grant Funding at the Camden Area Health Education
Center, New Jersey. We also are grateful to Community
Resources, LLC, for spearheading this process, as well as to
the Conference Facilitation team led by the Texas Health
Institute.
Additionally, we thank several individuals for their edito-
rial input as well as their encouragement as they reviewed this
manuscript. They include Dr. Hector Balcazar, Durrell Fox,
Eva Moya, Dr. Jorge Ibarra, Dr. Nel Martinez, Ifeanyi
Nwokeabia, Kay Swopes, Brooke Smith, Charles Rosenthal,
and the late Dr. Elizabeth C. Rosenthal.
NOTES
i The State of Minnesota passed state legislation to
reimburse CHWs for their services under the Medicaid,
MNCare and GMAC programs in 2007; in that same year,
they also filed for a Medicaid State Plan Amendment with
Centers for Medicare and Medicaid (CMS) to authorize a
broad-based reimbursement for CHW services to Medicaid
recipients. It also appears at the time of this writing that the
State of Massachusetts will file an 1115 Waiver application
with CMS for similar purposes. The Massachusetts Chapter
58, Act of 2006, law seeks to promote CHW sustainability.
ii
“Other stakeholders” include government and
private employers (health plans, hospitals, community health
centers, disease management contractors) and funding groups
such as private foundations, state/federal agencies, and others
investing in CHW services, education–industry partnerships,
and CHW research.
iii The Office of Minority Health developed a Cultural
Competence Research Agenda
16
with a panel of experts in
minority health; a CHW Research Agenda was a part of that
larger agenda.
iv
A full list of conference participants can be found
in the conference report’s Executive Summary (available
online at http://www.famhealth.org/researchagenda.htm).
v
This CHW definition was developed by members
of the Executive Committee the APHA CHW SPIG with input
from CHW networks throughout the US. It was submitted to
the U.S. Department of Labor in 2006 proposing that CHWs
be an occupational category in the 2010 census. The American
Association of CHWs, established in 2005, has adopted this
CHW definition.
vi Several individuals and groups posed exciting new
ventures to participants, including the J. Scott, Center for
Sustainable Health Outreach, Georgetown University; L.
Tobler, National Council of State Legislatures; and H. Balcazar,
University of Texas at Houston, School of Public Health, El
Paso Regional Campus.
vii In a few cases, CHW network leaders may not have
perceived their input as important, possibly because they did
not see a link between their work and the CHW research
agenda. This could also in part be due to the fact that many
of the CHW organizations are new and growing, and that
mechanisms for taking a stance on an issue were not well
developed.
viii Durrell Fox, a nationally known CHW who serves
as a founding Co-Chair of the American Association of CHWs,
has long suspected that CHWs have played a significant field
role in health promotion and social psychology research.
Authors found that hypothesis compelling and have begun
initial research on that area in collaboration with D. Fox.
Initial findings are reported here.

235
Rosenthal et al. Community Health Worker Research Agenda
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