On May 16, 2018, Arizona’s 23rd Governor Douglas Ducey signed the CHW Voluntary Certification HB2324 legislation into law. The bill’s passage represented another step in a long journey initiated by the Arizona CHW Association (AzCHOW) to organize, support, and build recognition for CHWs. It also represented the unification of the two major CHW workforces in the state,
promotoras and CHRs. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and
promotoras. The policy development process, which began long before voluntary certification became the desired outcome, clarified to the stakeholders that both groups shared the same profession, encountered many of the same challenges, and most importantly, had greater political power when they worked together. In fact, in a state reluctant to approve any new regulation [
16], it is unlikely the legislation would have passed without unified support of the
promotora workforce and Tribal CHR programs. In this paper, we seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the a US and beyond. We focus on aspects of the policy development and advocacy process to underscore key decisions that contributed to successful passage of the law.
A sister state to Sonora, Mexico and a geographic region populated by 21 federally recognized American Indian Tribes with Reservation lands, Arizona has a rich and diverse cultural heritage. Tribal reservations make up over a quarter of Arizona’s land base, and Arizona has the 3rd largest American Indian population of any state, comprising 5–6% of Arizona’s total population [
17]. One quarter of Arizona’s residents identify as Latino, the majority of whom are concentrated in US-Mexico border counties and are of Mexican origin [
18]. While this diversity is an asset, the health of the state is challenged by political, economic, and social conditions that disproportionally affect American Indians and Latinos [
17,
19].
As in many states, CHWs have a historical and ongoing role in addressing Arizona’s health disparities and specifically in building bridges between health and human services and vulnerable communities [
20]. Unfortunately, and perhaps reflective of bias within the health system, CHWs earn only minimum wage on average in Arizona and many are grant funded and have little job security [
21]. Very few organizations that hire CHWs have internal structures that ensure ongoing training or support CHW promotion within the job CHW designation. Further, no external accrediting structure exists through which a CHW’s work experience is recognized financially as she moves from one organization to another. It is thus imperative to improve working conditions for CHWs in Arizona as they are increasingly called upon to solve health care’s most pressing health issues both in the state and across the nation [
8]. One strategy for improving the compensation, mobility and sustainability of the workforce is to formally assess and recognize core competencies and scope of practice through a state-administered certification program.
CHRs were among the first CHWs in Arizona. In the 1960s, American Indian communities in the US identified the need and advocated for community health professionals that would improve cross-cultural communication between American Indian communities and predominantly non-American Indian health care providers. This advocacy led to the emergence of a federally funded CHR program. In 1969, Congress appropriated funds for the CHR Program as a component of health care services of American Indian people [
22]. The CHR Program is appropriated funding by Congress every year and is administered by the federal Indian Health Service (IHS). Most CHR programs are contracted/compacted by Tribes from the IHS. The CHR programs direct well-trained, community-based, health care professionals, designed to integrate the unique support of Tribal life with the practices of health promotion and disease prevention. The CHR workforce acts as a liaison and advocate for clients to assist them in meeting their health care needs, while upholding traditions, values, language and cultural beliefs of the individuals they serve [
23]. Existing literature on CHR programs focuses on evolving roles of CHRs [
24] and the evaluation of CHR training programs on health conditions [
25‐
27]. Of the 22 federally recognized Tribes in Arizona, 19 Tribes operate a CHR Program.
Promotora programs in Arizona originated from an academic-community partnership in the 1980s that developed a CHW prenatal intervention in a US-Mexico border community called
Comienzo Sano (Health Start) [
20,
28,
29]. The intervention was eventually adopted as an evidence-based program by the Arizona Department of Health Services (ADHS) and is now delivered by CHWs in county health departments and agencies across the state to provide services to rural and underserved mothers and children. Over the next decades, the partnership continued to champion the CHW/
promotora workforce in the border region, documenting effectiveness in cancer prevention [
30], chronic disease prevention and management [
31‐
33], and public health policy change [
20,
34]. Federally qualified health centers (FQHCs) and community-based organizations were pivotal in identifying grant opportunities and designing
promotora-driven programs [
32,
33,
35,
36]. The need to secure grant funding, while destabilizing for the programs, and the CHW/
promotoras working in them, also contributed to developing a strong evidence-base for CHW programs because they required rigorous evaluation. Notably, the
promotora workforce originated in a community-based model [
28] in which they employed an array of methods, including community organizing, to champion the needs of marginalized populations such as farmworkers [
20]. Growing evidence led to proliferation of CHW/
promotora programs beyond the border region, as well as their integration into primary care service delivery [
37], both as part of care teams and through community–clinical linkage models [
38]. However, the prevailing issue of workforce sustainability remained largely unaddressed.
The emergence of the Arizona Community Health Worker Association (AzCHOW) was essential to the development of the CHW workforce. As an organization of, by, and for CHWs, AzCHOW was formally established in 2001 by a group of CHWs who identified the need to create a forum to inform and unite culturally diverse CHWs of all disciplines and to strengthen the professional development of the CHW workforce through training, resource sharing, and collaborative opportunities with community, government, health, and educational institutions. Over 20 years, AzCHOW engaged in activities designed to cultivate a collective voice for CHWs in addressing relevant policy and sustainability issues, provide appropriate training opportunities, and promote expansion of the CHW workforce. CHRs served on the board of AzCHOW and participated in training events; however, full representation of this workforce in statewide initiatives was historically lacking. As a CHW-driven organization, however, AzCHOW was the natural leader to bring CHRs and promotoras together to consider statewide CHW voluntary certification.