Locally Recruited Lay Advisors Contribute to Community Health
In 1998, Freedom from Hunger, a California-based organization that addresses issues of hunger and poor nutrition, began the replication and institutionalization of a program to train lay health advisors in several Southern states.
They began this effort in 1988 by training lay health advisors in three rural Mississippi communities in an effort to increase access to health care services there, an effort known as the Community Health Advisor Network (CHAN).
The CHAN program office:
- Contracted with state agencies or schools of public health to implement CHAN projects.
- Developed training materials and provided technical assistance to state and local projects, including six conferences.
- Developed a monitoring system and conducted evaluations.
- Produced a videotape and published a quarterly newsletter.
- Was the subject of a profile in Health magazine.
After the Grant
- In Mississippi and Alabama, CHAN projects continue, along with newer initiatives in Illinois, Texas, and Delaware.
- The University of Southern Mississippi and the Harrison Institute for Public Law at Georgetown University Law Center received $2 million in federal funding in 1999 to establish the Center for Sustainable Health Outreach, which provides support and technical assistance to community health workers and program staff.
- In August 2006, RWJF made a grant (ID# 055510) to Georgetown University Law Center to integrate community health workers into the health care system by creating a national network to strengthen and sustain their workforce.
The Robert Wood Johnson Foundation (RWJF) supported this effort with three grants. The first grant (ID# 020096) supported a planning project to determine the feasibility of replicating CHAN in three states Alabama, Arkansas, Georgia and in additional Mississippi communities.
The second grant (ID# 023760) funded expansion in Mississippi and Arkansas. Alabama and Georgia implemented CHAN projects through other funding.
The final grant (ID# 029271) provided continued support for CHAN's training and technical assistance efforts and supported the transfer of the CHAN program office to the University of Southern Mississippi's (USM) Center for Community Health.
Community health advisors are lay volunteers who help families, friends, and neighbors to better understand their health problems and use existing services.
In 1988, Freedom from Hunger, a California-based organization that addresses issues of hunger and poor nutrition, developed the Community Health Advisor Network (CHAN) in Mississippi.
This effort (known locally as Partners for Improved Nutrition and Health, or PINAH), was based on the assumption that "natural helpers" exist in low-income communities and that these community leaders can be identified, mobilized, and trained to provide:
- Assistance (including outreach, referral, and transportation scheduling).
- Community action (coalition-building, advocacy with health service organizations, and development of community-managed projects).
CHAN began as a three-year pilot project in three rural communities in Humphreys County, Miss., and trained 52 community health advisors. Freedom from Hunger collaborated with two local organizations on the project the Delta Hills Public Health District of the Mississippi Department of Health and the Mississippi Cooperative Extension Service.
Findings of an Evaluation
An evaluation by the University of North Carolina Graduate School of Public Health found that each lay advisor was assisting an average of seven individuals per week by the end of the project.
Program staff estimated that community health advisors were reaching half the low-income population in the county every six months. The evaluation suggested that they were reaching people who did not otherwise have contact with public health services.
Local health and social service agency officials reported a significant increase in the number of referrals from individuals and groups in the community as a result of the CHAN project.
The evaluators also found that people in the communities served became better able to articulate their concerns and needs and manage relations with service agencies, local business, and government.
An Expansion Before RWJF Funding
At the end of the pilot project, the Mississippi Department of Health provided continuation funding to enable the initiative to expand to two additional counties.
A number of communities and state officials from Alabama, Louisiana, Arkansas, and Mississippi expressed interest in replicating the project in additional sites in the South.
However, no mechanism existed to facilitate the development of the community-state partnerships that were required if the program were to be replicated.
The aim of these three grants from RWJF was to replicate and institutionalize CHAN in additional states.
- The first grant (ID# 020096) supported a planning project to determine the feasibility of replicating CHAN in three states Alabama, Arkansas, Georgia and in additional Mississippi communities.
- Based on this planning, RWJF made a second grant (ID# 023760) that expanded CHAN in Mississippi and allowed the grantee to implement CHAN in one site in Arkansas.
Although the first grant had developed a plan to expand CHAN to three additional states, RWJF asked the grantee to scale the project back to these two states in order to reduce the cost of the project. CHAN planned to train 400 community health advisors in Mississippi and Arkansas in addition to the 127 community health advisors already working in seven Mississippi communities.
Independently of the RWJF grant, Alabama, Georgia, and Florida also decided to implement the program, with the RWJF-funded CHAN project providing technical assistance and training.
The funding also included an evaluation of all CHAN projects. RWJF expected that the implementing organizations would assume the entire cost of the program at the end of the grant period.
- The final grant (ID# 029271) provided continued support for CHAN's training and technical assistance efforts in the southeastern United States, including continued curriculum development and expansion.
It also supported the program's transfer to University of Southern Mississippi's Center for Community Health, to provide a permanent institutional base for CHAN.
A Committee of Advisors (see the Appendix) provided overall guidance to the project.
During the course of this project, Freedom from Hunger also received funding totaling $365,672 from a number of other sources, including the Fannie Mae Foundation, the Foundation for the Mid South, the Mary Reynolds Babcock Foundation, Metropolitan Life Foundation, Pfizer, the Public Welfare Foundation, and the William Randolph Hearst Foundation.
The implementing organizations in each state also contributed substantial resources to the effort.
The project produced a videotape on CHAN and the community health advisor program, which is used to market and explain the program and services offered through CHAN.
Staff have made numerous presentations about CHAN, participated in two press conferences, and disseminated a fact sheet.
In 1996 and 1997, CHAN published Networking, a quarterly newsletter distributed to 400 people. A profile of CHAN appeared in Health magazine.
The project provided extensive materials about the program and expansion efforts to the federal Centers for Disease Control and Prevention (CDC) for inclusion in the CDC's clearinghouse on lay health programs. (See the Bibliography for details.)
CHAN also held a number of conferences including its Unity Conferences in Gulfport, Miss.
Results of the Full Project
- Over the course of this project, CHAN provided training and technical assistance supporting local initiatives in five states: Mississippi, Arkansas, Alabama, Georgia, and Florida. Training in Alabama, Georgia, and Florida was not supported by RWJF grants, but it took place during the grant period and some technical assistance was provided. CHAN also began training in Illinois, again not supported by RWJF.
- According to the 1996 evaluation conducted under ID# 023760, in 1996, 61 community facilitators and 440 community health advisors were working at 19 CHAN sites, and they were reaching an estimated 40 percent of all individuals living below the poverty level in those communities. A description of activities in each state appears below. Evaluators had a difficult time securing data from the projects, and found that most of the sites were still in the developmental stage. The evaluators suggested several program modifications, listed under Lessons Learned, to improve future evaluation efforts.
- The project produced training materials including a community facilitator manual and a Community Health Advisor Training Curriculum. These materials can be used by other projects that would like to replicate this approach to training lay health advisors. The health advisor training curriculum is available in both English and Spanish. A curriculum module on managed care was developed and was undergoing evaluation at the end of the project (ID# 029271). The community facilitator manual gives instructions to facilitators on how to implement these projects.
- Six multi-state conferences provided opportunities for project planning, training, and technical assistance. Technical assistance also was provided through training workshops, telephone consultation, and resource sharing.
- Evaluators completed separate evaluations of both the pre-grant pilot project and the grant project's progress in 1994. A monitoring system was developed to collect key program data, and sites were trained in its use.
- The CHAN program was transferred to the University of Southern Mississippi's Center for Community Health, which provides a permanent institutional base for the network as well as access to the resources of a major university.
State by State Results of the Project
- Mississippi: Over the course of the three grants, the state health department expanded the project to a total of eight sites and community facilitators trained 137 new community health advisors. In addition, the University of Southern Mississippi trained nine community health advisors in Picayune, Miss. The community health advisors held a number of activities, including health fairs, to heighten awareness of health resources. In one community, community health advisors identified fires as a serious problem and educated residents about smoke detectors and the safe use of space heaters. Another community started an after-school choir for girls as a way of preventing teenage pregnancies. According to the supervisor, none of the girls have become pregnant. Community health advisors awarded ribbons to stores that refused to sell cigarettes to minors. In one rural community where hypertension was a common problem, community health advisors helped build a walking trail on a hospital campus.
- Arkansas: The Arkansas Department of Health established a community health advisory program in Gould, Ark., and trained 18 community health advisors. In 1994, the community health advisors sponsored a Youth Drug Prevention Retreat, carried out health promotion activities (including fitness), developed leadership skills among youth to address substance abuse and sponsored 18 students who attended the Annual Governor's Youth Conference on Alcohol, Tobacco and Other Drugs, and provided service opportunities such as city beautification projects for youth. In 1995, student leaders at the University of Arkansas, Monticello, were trained as community health advisors to work with the college population. The university program is no longer active; the CHAN project director at USM has no recent information on the Gould program. High staff turnover at the state level made it difficult to sustain the program, and Arkansas did not implement all elements of the CHAN program, according to the CHAN project director at USM.
- Alabama: After Mississippi, Alabama has been the most active program, with projects in three neighborhoods in Birmingham and in two rural communities. The University of Alabama at Birmingham School of Public Health (UAB) is the implementing organization. In the rural areas, community health advisors focused on reducing cardiovascular disease through cooking classes and aerobics and walking programs. In the urban areas, the community health advisors have focused on neighborhood beautification (believing that feeling good about where you live can foster better health), participating in local elections, engaging in regular physical exercise, tutoring and mentoring kids, and taking on absentee landlords who take advantage of renters.
- Georgia: The Georgia Department of Human Resources was the original implementing organization and trained 32 community health advisors in a Hispanic community in Gainesville. It withdrew when funding from Metropolitan Life was delayed. Georgia Legal Services, which works closely with undocumented Hispanics, assumed sponsorship, but the program has since become inactive.
- Florida: About 25 staff members of the Duvall County Health Department received some training as community facilitators. Some of those staff members trained teen health advisors to discourage their peers from becoming pregnant. Adult mentors were also being trained to support the teen health advisors. The community facilitators, however, were assigned other tasks, and never completed training for teen health advisors.
- Illinois: The Cook County Health Department, based in Oak Park, Ill., sent four health educators for community facilitator training in 1997 and began training its first class of community health advisors later that year.
- Negotiate formal memoranda of understanding with implementing organizations. When the CHAN program began, the project could not offer financial support to programs in Alabama and Florida and did not negotiate formal memoranda of understanding or require the agencies to fully participate in the monitoring and evaluation system. That limited the project's ability to report outcomes for these programs and to provide adequate technical assistance. The project director recommended clearly defining partner expectations during the recruitment process and instituting formal memoranda of understanding.
- Design a more cost-effective training and technical assistance system for all program partners. Supporting design work on training and technical assistance up front can result in cost savings later.
- Provide adequate training on the reporting requirements from sites so that clear and consistent data can be recorded at all sites. The program coordinator should consult directly with community facilitators and evaluators in each state to assure clear record keeping of activities. In several sites, the facilitators and health advisors did not maintain clear records of their activities.
- Assign responsibility for compliance with reporting requirements to a single person at the implementing organization that oversees the project. This person should ensure that all reports are received in a timely and complete manner. Make monies granted contingent upon reporting compliance.
AFTER THE GRANT
The University of Southern Mississippi has received $2 million in funding from the U.S. Department of Health and Human Services to set up, in conjunction with the Harrison Institute for Public Law at Georgetown Law Center, the Center for Sustainable Health Outreach.
It is designed to offer training to community health workers and serve as the first national resource center for community health workers. The organization, based in Mississippi, focuses on advocacy, credentialing issues, and professional education, and will offer technical assistance and support to developing lay health advisors.
The Center for Health Promotion at UAB, which runs the community health advisor network in Alabama, has recently received funding for this program for the next five years from the CDC through a congressional appropriation.
CHAN projects continue to operate in Mississippi, Alabama, and Illinois, with newer projects in Texas and Delaware.
In August 2006, RWJF made a grant (ID# 055510) to Georgetown University Law Center to integrate community health workers into the health care system by creating a national network to strengthen and sustain their workforce.
GRANT DETAILS & CONTACT INFORMATION
Development of Community Health Advisor Networks in the Southeastern United States
Freedom from Hunger (Davis, CA)
- Feasibility of Health Advisor Networks in Underserved Communities
Amount: $ 162,446
Dates: September 1992 to March 1994
- Development of a Community Health Advisor Program in Two Southern States
Amount: $ 441,202
Dates: July 1994 to December 1996
Agnes W. Hinton, Ph.D., R.D.
University of Southern Mississippi (Hattiesburg, MS)
- Technical Assistance for a Community Health Advisor Network in the Southeastern United States
Amount: $ 132,088
Dates: August 1996 to December 1997
Agnes W. Hinton, Ph.D., R.D.
Committee of Advisors
Judy Barber, M.S.W., A.C.S.W.
Mississippi State Department of Health
Rev. Rims Barber
Human Services Coalition
J. Nell Brownstein, Ph.D.
Centers for Disease Control and Prevention
Teresa Carithers, M.H.S., R.D.
University of Mississippi Medical Center
New Orleans, La.
Rep. Alyce Clarke, M.S., L.N.
Mississippi House of Representatives
Ulysses Conley, M.P.P.A.
Mississippi State Department of Health
Catherine Cowell, Ph.D.
Professor of Nutrition at Columbia University
New York City, N.Y.
A.L. Dukes, M.S.
Christopher Dunford, Ph.D.
Freedom from Hunger
Eugenia Eng, Ph.D.
University of North Carolina at Chapel Hill
Chapel Hill, N.C.
Sharon Farley, Ph.D., R.N.
Auburn University at Montgomery
Deborah Frazier, R.N.
Arkansas Department of Health
Little Rock, Ark.
Annie Greer, L.N.
Friends of Children of Mississippi
John Hatch, Dr.P.h, M.S.W.
University of North Carolina at Chapel Hill
Chapel Hill, N.C.
W.D. Hawley, M.D., M.P.H.
Health Advocacy Consultant
Carol Hickey, Ph.D., R.D.
University of Alabama at Birmingham
School of Public Health
Agnes Hinton, Dr.Ph., R.D.
University of Southern Mississippi
Mildred Kaufman, M.S., R.D.
Professor Emeritus at University of North Carolina at Chapel Hill
Jun Y. Lee
Center for Communitarian Policy Studies
Rebecca A. Mullis, Ph.D., R.D.
Georgia State University
Jason Newman, J.D.
Harrison Institute of Law at Georgetown University
Food Research and Action Center
Alfio Rausa, M.D.
Delta Hills Public Health District III
E. Lee Rosenthal, M.P.H.
Ann E. Casey Foundation
Lisabeth R. Schorr
Harvard Lecturer and Author
Sarah Samuels, Dr.Ph.
Health Program and Policy Consultant
Aaron Shirley, M.D.
Jackson-Hinds Comprehensive Health Center
Foundation for the Mid-South
Rev. Bertha Thurman
Second United Baptist Church
Ellen Vor der Bruegge, M.P.H., M.S.
Freedom from Hunger
Royal Walker, Jr., J.D.
University of Southern Mississippi
Ruth Hand Wilson
Volunteer Services Consultant
Allison Yates, Ph.D., R.D.
University of Southern Mississippi
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Beardshall AH and Laufer RH. Community Health Advisors Network Final Evaluation Report. Hattiesburg, Miss.: Institute for Disability Studies, University of Southern Mississippi, 1996.
CHAN Community Facilitator Implementation Manual, Jackson, Miss.: Freedom from Hunger, 1999.
Community Health Advisor Training Curriculum. Hattiesburg, Miss.: University of Southern Mississippi, 1994.
McNelly, B, and Kingsbury, J (eds.): Community Health Advisors in Mississippi: Do They Make a Difference? Evaluation Summary for Freedom from Hunger's Five-Year Project in Mississippi. Davis, Calif.: Freedom from Hunger, 1993.
Brochures and Fact Sheets
Community Health Advisor Network (handout), Jackson, Miss.: Freedom from Hunger/CHAN, 1993.
CHAN Fact Sheet, 1996.
Networking, Jackson, Miss.: Freedom from Hunger/CHAN. Sent out to more than 400 network members and interested persons in April, June and October 1996 and January 1997.
"Community Health Within Our Reach," May 7, 1993, Jackson, Miss. Attended by more than 100 people including representatives from public health departments, cooperative extension services, universities, faith communities, city governments, and nonprofit organizations. Also, community health advisors, medical providers, and state legislators from Alabama, Arkansas, Georgia, Louisiana and Mississippi.
- Lisabeth Schorr, "Community Health: Within Our Reach."
- Diana Hargrove and Lela Skelton, "Building Participation."
- Linda Southward, "Coalition Building."
- Kaye Bender, "Discovering Your Community's Health Needs."
- George Penick, Jr., "Fund Raising."
- Therese Hanna," Grantsmanship."
- Bessie Smith, "Identifying and Recruiting Community Helpers."
- Michelle Bressler, "Presentation of 5 Year Evaluation."
- Agnes Hinton, "Where Do We Go From Here?"
"Multi-State Conference," August 1993, Jackson, Miss. Attended by 20 participants including representatives from the Alabama Department of Public Health, West Alabama Health Services, University of Alabama at Birmingham School of Public Health, Arkansas Department of Health, Georgia Department of Human Resources, Mississippi State Department of Health, Freedom from Hunger/Davis, and Freedom from Hunger/CHAN.
"CHAN Unity Conference Reaching Out Beyond Mississippi," Jackson, Miss., October 35, 1994.
Presentations and Workshops
- "History of Mississippi CHAN/PINAH Program," Chris Dunford, Alfio Rausa, Ed Thompson, and Eugenia Eng.
- "Freedom from Hunger/CHAN Developments and Expansion," Agnes Hinton, Ann Beardshall, Joyce Gray, Ellen Jones, and John Mondy.
- "State Presentations of Program Plans," Representatives from Alabama, Arkansas, Georgia, and Mississippi.
- "Visions for the Future of Health Advisors," Agnes Hinton.
- "Facilitation Methods I Training," Institute of Cultural Affairs.
"CHAN Unity Conference," Jackson, Miss., 1995.
"CHAN Unity Conference," September 1517 1996, Hattiesburg, Miss. Forty-five participants from eight states attended. Presentations from representatives of the Food Research Action Center (FRAC), Mothernet/IMED, Harrison Institute for Public Policy of the Georgetown University Law School, and the National Community Health Advisor Study. The conference also had four interactive workshops.
"Unity Conference '97," co-sponsored by CHAN and the University of Alabama at Birmingham School of Public Health, Center for Community Resource Development, Birmingham AL. Some 29 participants from 7 states attended along with UAB faculty, students, and local Community Health Advisors. Workshops included community health advisors program implementation, evaluation and support and Institute of Cultural Affairs Technology of Participation Methods. Keynote speakers included Erna Kock, Harrison Institute of Georgetown Law School; Dr. Nell Brownstein, Health Education Specialist, Centers for Disease Control and Prevention; and Angela Borbon, speaker on community health workers.
Presentations and Testimony
Agnes Hinton, Mississippi Dietetic Association, March 1993.
Agnes Hinton, preconference meeting of the Gulf Coast Conference on Developmental Disabilities, June 1993, Alabama.
Agnes Hinton, University of Tennessee conference on Health Care for the Poor and the Uninsured, August 1993.
Agnes Hinton, Mississippi Primary Care Association, September 1993.
Agnes Hinton, Kellogg Foundation Project Officers, September 1993.
Agnes Hinton, USDA-funded Interact program, October 1993.
Agnes Hinton, community services class of Tougaloo College, November 1993, Mississippi.
Agnes Hinton, congressional briefing on National Community Health Advisor Act," to US Senators and Representatives, Washington, D.C. 1995. Written request from Rep. Bernard Sanders (Vt.).
Agnes Hinton, International Association of Facilitators, workshop on Enabling Natural Leaders to Achieve Healthier Communities, January 15, 1995.
Agnes Hinton, Arkansas Dietetic Association, roundtable discussion, exhibit, and speech about partnering with the community, April 67, 1995.
Agnes Hinton, Lower Mississippi Delta Nutrition Intervention Research Project Vision Meeting, April 26, 1995.
Agnes Hinton, Lower Mississippi Delta Nutrition Intervention Research Project Data Task Force Meeting, overview of CHAN Monitoring and Evaluation System, June 1516, 1995.
Agnes Hinton, workshop on Enabling Natural Leaders to Achieve Healthier Communities, International Association of Facilitators, January 15, 1995.
Agnes Hinton, plenary speaker on partnering with the community and roundtable discussion. American Dietetic Association, April 67, 1995.
Agnes Hinton, program description. Lower Mississippi Delta Nutrition Intervention Research Project Visioning Meeting, April 26, 1995.
Agnes Hinton, overview of CHAN Monitoring and Evaluation System, Delta Task Force meeting, June 1516, 1995.
Agnes Hinton, "CHAs as Part of National Health Reform," at the American Public Health Association Annual Meeting, November 1, 1995.
Agnes Hinton, Centers for Disease Control National Chronic Disease Conference, November 1996, Phoenix, Ariz.
Agnes Hinton, American Public Health Association, November 1996, New York, N.Y.
Agnes Hinton, National Heart Lung Blood Institute, Annual Conference, 1997, San Francisco, Calif.
Agnes Hinton, Chronic Disease Conference, Centers for Disease Control, 1997, Atlanta, Ga.
Agnes Hinton, The University of Tennessee at Knoxville Video Teleconference for Public Health Nutritionists, March 1997, Knoxville, Tenn.
Agnes Hinton, Mississippi Public Health Association Annual Meeting, October 1997.
Agnes Hinton, American Public Health Association, November 1997, Indianapolis, Ind.
Agnes Hinton, The National Heart, Lung, Blood Institute National Cardiovascular Conference, February 1998, San Francisco, Calif.
Agnes Hinton, The Bureau of Primary Health Care, Building Healthy Partnerships: Supporting Community-Based Outreach, June 1998, Washington, D.C.
Agnes Hinton, "Community Health Advisory Program: Reducing Risk for Cardiovascular Disease in Minorities," at the National Teleconference with Surgeon General, 1998.
World Wide Web Sites
www.usm.edu/csho provides information about the Community Health Advisor Network. Hattiesburg, Miss.: The University of Southern Mississippi. May 1999. Average of 75 hits/views per month.
Audio-Visuals and Computer Software
Community Health Advisors Network (videocassette), Hattiesburg, Miss.: The University of Southern Mississippi, 1997.
Press conference with five journalists to announce program funding, Jackson, Miss., 1993.
Press conference with approximately ten journalists to announce program funding, Atlanta, Ga., 1995.
"Hope in Mississippi," in Health, March/April 1993.
Report prepared by: Susan G. Parker
Reviewed by: Robert Narus
Reviewed by: Richard Camer
Program Officer: Michael Beachler
Program Officer: Janet Heroux