Don't change who we are but give us a chance: confronting the potential of community health worker certification for workforce recognition and exclusion

Background

For community health workers (CHWs) and promotores de salud (CHWs who primarily serve Latinx communities and are grounded in a social, rather than a clinical model of care), the process of certification highlights the tension between developing a certified workforce with formal requirements (i.e., certified CHWs) and valuing CHWs, without formal requirements, based on their roles, knowledge, and being part of the communities where they live and work (i.e., non-certified CHWs). California serves as an ideal case study to examine how these two paths can coexist. California’s CHW workforce represents distinct ideologies of care (e.g., clinical CHWs, community-based CHWs, and promotores de salud) and California stakeholders have debated certification for nearly twenty years but have not implemented such processes.

Methods

We employed purposive sampling to interview 108 stakeholders (i.e., 66 CHWs, 11 program managers, and 31 system-level participants) to understand their perspectives on the opportunities and risks that certification may raise for CHWs and the communities they serve. We conducted focus groups with CHWs, interviews with program managers and system-level participants, and observations of public forums that discussed CHW workforce issues. We used a thematic analysis approach to identify, analyze, and report themes.

Results

Some CHW participants supported inclusive certification training opportunities while others feared that certification might erode their identity and undermine their work in communities. Some program managers and system-level participants acknowledged the opportunities of certification but also expressed concerns that certification may distance CHWs from their communities. Program managers and system-level participants also highlighted that certification may not address all challenges related to integrating CHWs into health care systems. CHWs, program managers, and system-level participants agreed that CHWs should be involved in certification discussions and decision making.

Conclusions

To address participant concerns, our findings recommend California stakeholders build a voluntary certification process structured with multiple pathways to overcome entry barriers of traditional certification processes, maintain CHW identity, and protect diversity within the workforce. Positioning CHWs as decision makers will be critical when designing state certification processes.

Patient perceptions of a decision support tool to assist with young women's contraceptive choice

OBJECTIVE

Contraceptive decision support tools (DSTs) have been suggested as a way to provide patient-centered contraceptive care, but little is known about the role they play in women's decision-making. The aim of this study is to understand patients' perceptions of the value of a contraceptive DST.

METHODS

We conducted 21 semi-structured interviews with unmarried women aged 18-29 from an integrated health care system who viewed the DST. Thematic analysis was conducted to identify common themes in the participants' experience.

RESULTS

Four themes were identified: Informative; Narrowing down options; Tool vs. doctor; and Preparation for a clinical visit. In general, participants felt the tool was valuable because it provided them relevant information and facilitated their decision-making process by narrowing down contraceptive options. Participants felt the tool could prepare them for a visit with their health care provider by helping them identify questions for their provider, but also saw distinctions between the DST and what their provider could offer.

CONCLUSION

Contraceptive DSTs are valuable to their users when they include information on contraceptive attributes women deem important and allow for user-driven tailoring.

PRACTICE IMPLICATIONS

Contraceptive DSTs may address patient informational needs and can serve as a complement to provider counseling.

Young Women's Contraceptive Decision Making: Do Preferences for Contraceptive Attributes Align with Method Choice?

CONTEXT

Understanding how women's preferences for certain attributes of contraceptive methods relate to their method choice can inform the content of contraceptive counseling.

METHODS

Data from 715 women aged 18-29 who had ever used contraceptives were drawn from the 2009 National Survey of Reproductive and Contraceptive Knowledge. Chi-square tests and multivariable logistic regression analyses were used to examine how women's preferences for specific contraceptive attributes were related to their social and demographic characteristics and their current contraceptive choice.

RESULTS

The majority of women considered it extremely important for a method to be very effective at preventing pregnancy (79%) and to be effective at preventing HIV and STDs (67%); fewer than one-quarter felt similarly about a method's being hormone-free (22%). Women who felt it was quite or extremely important for a method to be very effective at preventing pregnancy were not more likely to use the most effective methods than were women who considered this attribute not at all or only slightly important. Women who considered it quite or extremely important for a method to be hormone-free were less likely than others to use hormonal methods (odds ratio, 0.4), and women who considered STD protection quite or extremely important had elevated odds of relying on condoms alone, rather than on an effective contraceptive method alone (3.6).

CONCLUSIONS

Most women desire a very effective method for pregnancy prevention, but it is unclear how this translates to their contraceptive use. The associations between women's preferred contraceptive attributes and method choice warrant further attention.

Effect of abortion vs. carrying to term on a woman's relationship with the man involved in the pregnancy

CONTEXT

When a woman who seeks an abortion cannot obtain one, having a child may reshape her relationship with the man involved in the pregnancy. No research has compared how relationship trajectories are affected by different outcomes of an unwanted pregnancy.

METHODS

Data from the Turnaway Study, a prospective longitudinal study of women who sought abortion in 2008-2010 at one of 30 U.S. facilities, are used to assess relationships over two years among 862 women who had abortions or were denied them because they had passed the facility's gestational age limit. Mixed-effects models analyze effects of abortion or birth on women's relationships with the men involved.

RESULTS

At conception, most women (80%) were in romantic relationships with the men involved. One week after seeking abortion, 61% were; two years later, 37% were. Compared with women who obtained an abortion near the facility's gestational age limit, women who gave birth had greater odds of having ongoing contact with the man (odds ratio at two years, 1.7). The odds of romantic involvement at two years did not differ by group; however, the decline in romantic involvement was initially slower among those giving birth. Relationship quality did not differ between groups.

CONCLUSIONS

Giving birth temporarily prolonged romantic relationships of women in this study; most romantic relationships ended soon, whether or not the woman had an abortion. However, giving birth increased the odds of nonromantic contact between women and the men involved throughout the ensuing two years.

Welfare leavers' use of Medicaid transitional medical assistance in California, 1993-1997

Using administrative and survey data, we estimate participation rates in Transitional Medical Assistance (TMA) for the period 1993-97 by California welfare leavers during their first six months post-welfare. We find that although many welfare leavers were eligible for TMA (35% to 47% of exiters), only 26% of eligible people were enrolled in the TMA program. Another 14% were covered by non-TMA Medicaid for the entire six months. Most TMA-eligible exiters had Medicaid coverage (all of it non-TMA) for less than six months (49%) or no Medicaid coverage at all (11%). Supplementary analyses using data from the National Survey of America's Families indicate that if fully implemented, TMA could have substantially reduced uninsurance among welfare leavers.

Perceptions of hormonal contraceptive safety and side effects among low-income Latina and non-Latina women

OBJECTIVES

We explored perceptions of the safety and side effects of oral and injectable hormonal contraceptives among low-income women at high risk of unintended pregnancy.

METHODS

Overall safety perceptions, specific health concerns, and the relationship between these safety perceptions and contraceptive choices were determined by focus groups and questionnaires obtained from white non-Latina (n = 19), English-speaking (n = 21), and Spanish-speaking Latina women (n = 19).

RESULTS

Uncertainty or ambivalence about the safety of oral and injectable contraceptives was reported by 41% and 70% of respondents respectively, while 20% considered these methods to be mostly harmful. Personal experiences and stories from social networks proved to be more salient than medical opinions in shaping safety perceptions. Side effects and concerns about long-term health effects were common themes. While white non-Latina women focused predominantly on physical side effects, emotional side effects also contributed to Latinas' decisions about contraceptive switching. Spanish-speaking Latinas differed from English-speaking Latinas in other attitudinal dimensions, contraceptive use prevalence, and access to contraceptive services.

CONCLUSION

Low-income mothers lacked confidence in method safety and had many concerns about the side effects of oral and injectable contraceptives. Because such concerns can be a barrier to contraceptive use, these perceptions need to be corrected to encourage more effective use of hormonal methods and to prevent unintended pregnancies. Culturally appropriate interventions should focus on client-provider interactions, social networks, and access to care.

Informed policy making for the prevention of unwanted pregnancy. Understanding low-income women's experiences with family planning

California health and welfare officials asked the authors to identify ways that their programs could encourage service use among low-income women. The project posed a challenge: The clients wanted to identify supply-side barriers amenable to intervention, but prior research suggested other factors might be more influential. The approach was to examine service-related issues, but in the broader context of women's experiences. The authors identify factors amenable to intervention, including inaccurate beliefs about methods. Other important influences--such as instability of relationships, skepticism about planning, or unsatisfactory method experiences--may be beyond the reach of specific policies, but are nevertheless critical to understanding program context. Findings suggest that punitive messages and policies based on a simplistic model of behavior may be unrealistic and ineffective.

Little knowledge and limited practice: emergency contraceptive pills, the public, and the obstetrician-gynecologist

OBJECTIVE

To assess Americans' knowledge and attitudes about emergency contraceptive pills and the knowledge, attitudes, and practices of obstetrician-gynecologists with respect to emergency contraceptive pills.

METHODS

A random sample of a national cross-section of 2002 Americans, age 18 and older, including 1000 women and 1002 men, was surveyed by telephone between October 12 and November 13, 1994. A nationally representative sample of 307 obstetrician-gynecologists, whose names were drawn from the American Medical Association Physicians' Masterfile, was surveyed by telephone between February 1 and March 21, 1995. Both Surveys addressed knowledge and attitudes about unplanned pregnancy and contraception options, including emergency contraception. Despite response rates of 50 and 77%, respectively, both unweighted samples closely mirror the populations from which they were drawn.

RESULTS

Americans are not well informed about emergency contraceptive pills. Only 36% of respondents indicated that they knew "anything could be done" within a few days after unprotected sex to prevent pregnancy. Fifty-five percent said they had "heard of" emergency contraceptive pills, and only 1% had ever used them. Ninety-nine percent of obstetrician-gynecologists reported being "familiar" with emergency contraceptive pills. Twenty-two percent were "somewhat familiar." Among those who said they were "very familiar" with the method (77%), the majority considered emergency contraceptive pills to be "very safe" (88%) and "very effective" (85%). Overall, 70% of obstetrician-gynecologists surveyed said they had prescribed emergency contraceptive pills within the last year, but on an infrequent basis; 77% of those who prescribed emergency contraceptive pills did so five or fewer times.

CONCLUSION

Public knowledge about the availability and use of emergency contraceptive pills is limited, as is the practice of prescribing the pills among obstetrician-gynecologists. Because patients rely on health care providers for information on birth control, health care providers can improve knowledge about the availability of emergency contraceptive pills among their patients.

Public perceptions about unplanned pregnancy

A nationally representative telephone survey in 1994 of 2,002 adults indicates that 60% believe that unplanned pregnancy is a very big problem in the United States, and virtually all (90%) say it is at least a somewhat big problem. Two-thirds mistakenly believe that a larger percentage of women have unplanned pregnancies now than 10 years ago. A decline in moral standards is cited by 89% of respondents as contributing very much or somewhat to the problem. Lack of education is mentioned as a significant factor by 87%, and 88% see any of three barriers to contraceptive use--knowledge about use, access or cost--as being important factors. Never-married women with children, women in general, low-income respondents, Hispanics and those aged 65 or older are the most likely to believe that barriers to contraceptive access contribute very much to unplanned pregnancy; they are especially likely to cite cost or an inability to obtain contraceptives.

The effects of contraceptive education on method use at first intercourse

Despite long-standing public support for sex education in the schools, it has been difficult to show concrete effects of sex education on sexual and contraceptive behavior. Data from the 1988 National Survey of Family Growth indicate that exposure to a formal contraceptive education program increases the likelihood that a teenage woman will use a contraceptive method at first intercourse. According to the results of a multivariate analysis, the odds that a young woman will use any method and the odds that she will use a condom increase by about one-third following instruction about birth control; the effect on the likelihood of pill use, however, is nonsignificant. If contraceptive education occurs in the same year that a teenager becomes sexually active, the odds of any method use and of condom use are increased by 70-80%, and the odds of pill use are more than doubled. The results also suggest that with greater educational efforts, the proportion of teenagers who use condoms at first intercourse could increase from 52% to 59%, while the proportion using no method might decrease from 41% to 33%.

Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care

OBJECTIVES

This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers.

METHODS

In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating households recorded data on children's health status and use of medical care.

RESULTS

The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently.

CONCLUSIONS

It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients. However, these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care.

The effect of marital disruption on children's health

This study uses retrospective illness histories to investigate whether children's health deteriorates after parental separation. Separation is associated with illness in a multivariate cross-sectional analysis as well as in an analysis of a sample of disrupted children only, in which illness rates before and after separation are compared. Three explanations are hypothesized: (1) divorce reduces the resources available to children, (2) the stress of divorce depletes children's health, and (3) frailer children are selected into divorce. The first hypothesis has stronger support than the second, but the data are too poor for a rigorous test of either. The selection hypothesis is not supported.

The Effect of Marital Disruption on Children’s Health

This study uses retrospective illness histories to investigate whether children’s health deteriorates after parental separation. Separation is associated with illness in a multivariate cross-sectional analysis as well as in an analysis of a sample of disrupted children only, in which illness rates before and after separation are compared. Three explanations are hypothesized: (1) divorce reduces the resources available to children, (2) the stress of divorce depletes children’s health, and (3) frailer children are selected into divorce. The first hypothesis has stronger support than the second, but the data are too poor for a rigorous test of either. The selection hypothesis is not supported.