A Snapshot of Oklahoma’s CHR/CHW Workforce: Results from the Region 6 Training Needs Assessment Survey, 2019

Abstract

Background –

The Region 6 South Central Public Health Training Center conducts needs assessments to inform the development of online trainings tailored to the HRSA Region 6 health and public health workforce. The purpose of this study was to assess Oklahoma’s Community Health Representative (CHR) / Community Health Worker (CHW) workforce characteristics, current trainings, and training needs to guide the development of online trainings.

Methods –

This survey-based needs assessment for health and public health workforce training needs asked about alternative job titles, top three health issues addressed, roles played, skills used, current trainings, and training needs. Descriptive statistical analysis provided insights about CHRs/CHWs. The Fisher’s exact test was used to compare frequency of responses between CHRs and CHWs, with p-values <0.05 considered significant. We analyzed qualitative data by using a modified content analysis.

Results –

Fifty-one self-identified CHRs/CHWs in Oklahoma participated in the 2019 regional health and public health training needs assessment. Most CHRs/CHWs were female and identified as “frontline public health workers.” Respondents reported a range of educational attainment and diverse job titles. CHRs worked at tribal health or public health organizations primarily in rural areas. Most CHWs worked in urban areas and were employed by state and local health departments or community-based organizations. CHRs/CHWs had a broad spectrum of roles and skills, with required trainings reflecting various organizational needs. CHRs/CHWs expressed strong interest in receiving additional trainings via multiple delivery formats.

Discussion and Conclusions –

Oklahoma’s CHRs/CHWs would benefit from and utilize workforce development, including trainings on a broad spectrum of roles and skills in multiple delivery formats. Potential employers and funders across the state would benefit from education on CHRs/CHWs as a workforce, team-integration, and sustainable funding.

BACKGROUND

In 2019, Oklahoma ranked 46^th in health outcomes among U.S. states.¹ Oklahoma had disproportionate poor health outcomes compared to national outcomes in terms of quality and length of life related to behavior, clinical factors, and social determinants of health.^1,2 In 2020, 21% of adults in Oklahoma reported fair or poor health (age-adjusted) compared to 17% of adults nationwide.² Oklahoma’s age-adjusted average number of physically and mentally unhealthy days reported in the past 30 days in 2020 were 4.5 and 5.9 days, compared to 3.8 and 4.0 days reported by U.S. adults, respectively.² In 2020, Oklahoma had 9,200 premature deaths (age-adjusted years of potential life lost before age 75 per 100,000 population) compared to 6,900 in the U.S.² Health outcomes differ significantly across the state’s 77 counties,^2,3 and health disparities affect minorities disproportionally.⁴ Poor health outcomes and disparities in Oklahoma can be reduced significantly by rein-forcing or creating behavioral, clinical, and social-economic factors that support long, healthy lives.²

Community health workers (CHWs) are effective in reducing chronic disease health disparities related to social determinants of health,^5,6 behavior,^7,8 and health care.^9,10 “CHWs” is an umbrella term that unites a diverse workforce of frontline public health workers known by many names (e.g. American Indian community health representative (CHR), promotora de salud, outreach worker, or patient navigator).¹¹ We use the term “CHRs” to refer to CHWs employed by American Indian tribal health or public health organizations, and “CHWs” to refer to workforce members who are outside tribal systems. To refer to both groups, we use the term “CHRs/CHWs.” In Oklahoma, CHRs are well established with access to a national foundational training, while CHWs are an emerging workforce¹² that does not yet have access to a foundational CHW training. In general, CHRs/CHWs are trained as public health professionals who serve as link between health/social services and communities, and who build individual and community capacity.¹¹ Some CHRs/CHWs may be trained to provide basic direct services such as taking blood pressure.

The Oklahoma Public Health Training Center (OPHTC) and its partners seek to strengthen the state’s frontline public health personnel, including CHRs/CHWs, in local, state and tribal public health agencies. The OPHTC and partners participated in a region-wide training needs assessment designed to guide development of online trainings. In this paper, we describe 2019 survey outcomes that introduce the CHR/CHW workforce in Oklahoma, and detail their self-reported responsibilities, current trainings, and expressed training needs.

METHODS

The Region 6 South Central Public Health Training Center (R6SCPHTC)

R6SCPHTC Partners.

Funded by the Health Resources & Services Administration (HRSA), and housed at the Tulane University School of Public Health and Tropical Medicine, the R6SCPHTC is one of ten regional public health training centers in the United States that supports the current and future public health workforce.¹³ Under Tulane’s leadership, the R6SCPHTC partners with organizations in Louisiana, Texas, New Mexico, Oklahoma, and Arkansas. In Oklahoma, the Oklahoma Public Health Training Center (OPHTC),¹⁴ the Southern Plains Tribal Health Board (SPTHB),¹⁵ and the Oklahoma Public Health Association (OPHA)¹⁶ collaborate in alignment with the R6SCPHTC mission.

R6SCPHTC Regional Survey.

The R6SCPHTC conducts recurring, anonymous, and confidential needs assessment surveys to inform the development of online trainings tailored to the HRSA Region 6 health and public health workforce. The Oklahoma partners implement the assessments along with their multi-state R6SCPHTC partners to identify training needs in each state and across the region.

SURVEY METHODOLOGY

Survey Development.

R6PHTC partners developed the 2019 needs assessment, organizing it into five sections with 52 mostly closed-ended questions focused on work experience and environment, training needs, access and logistics, demographic information, and resources. The OPHTC contributed five questions for CHRs/CHWs that asked about alternative job titles, top three health issues addressed, roles played, skills used, and required trainings. These questions and their responses were aligned with a 2014 National Community Health Worker Advocacy Survey,¹⁷ the Community Health Worker Core Consensus (C3) Project (henceforth called “C3 Project”) that generated recommendations on core CHW roles and competencies,¹⁸ and select HRSA clinical priorities (childhood obesity, opioids, and mental health).¹⁹

This R6SCPHTC’s training-related needs assessment data collection is considered to have exempt status by Tulane University’s Institutional Review Board (IRB). Before beginning the online survey, all potential participants were informed that its purpose was the development of future educational and training resources, that the survey was anonymous, and that responses were confidential. The survey took between 17–18 minutes to complete.

Data Collection.

R6SCPHTC state partners used their contacts of individuals and organizations to locally distribute and promote the survey. For five weeks in March and April 2019, the Oklahoma partners distributed the online survey via e-mail to professional contacts throughout the state. We estimated a combined target audience of 7,776 contacts representing public health organizations, networks, taskforces, and programs. Some of these contacts were known to employ CHRs or CHWs. Contacted organizations, in turn, were asked to forward the survey to their respective public health colleagues. While we can determine the initial number of survey recipients, we cannot estimate the actual number of surveys distributed. Survey responses went directly to the R6SCPHTC for data entry.

Data Analysis.

In September 2019, the R6PHTC central office at Tulane University released de-identified survey response data from Oklahoma survey participants who self-identified as CHRs/CHWs. We used this exploratory data to develop a descriptive snapshot of the characteristics (roles and skills) of Oklahoma’s CHRs/CHWs, currently required trainings, and expressed training needs. Data management was conducted using Microsoft Excel and SAS Software, Version 9.4 (Cary, Inc.). Question 4 (type of institution/organization respondents currently work for) was used to classify all responses into two groups (CHRs versus CHWs). We identified CHRs as those who indicated tribal health or public health organizations, and identified all others as CHWs. Descriptive statistics were determined for all self-identified CHRs/CHWs to provide insights about the combined workforce in Oklahoma, showing the summary and cumulative frequencies of the variables. In addition, responses from CHRs and from CHWs were analyzed individually and comparatively to identify potential workforce differences and training needs in these subgroups. Specifically, the Fisher’s exact test was used to compare frequency of responses between CHRs and CHWs, with p-values <0.05 considered significant.

We analyzed the responses to two open-ended questions about alternative CHR/CHW job titles and requested training topics. Using a modified content analysis,²⁰ we downloaded responses into word documents and organized responses with frequency of occurrence. Frequencies served the qualitative purpose of gaining a sense of relative importance, not statistical significance. Sorted responses were organized into categories. Where applicable, the C3 Project’s¹⁸ recommended roles served as categories to sort alternative CHR/CHW titles, and the C3 Project’s recommended skills served as categories to sort training topics. We report categories with specific responses for each qualitative question.

RESULTS

We received survey responses from 51 participants who self-identified as CHRs/CHWs, out of a total of 201 responses from Oklahoma. Select demographic and workforce characteristics of CHW survey participants in Oklahoma are presented in Table 1. Using an open-ended question, we asked survey respondents what other job titles, if any, they held, inviting up to three alternatives for “Community Health Workers.” Content analysis revealed diverse job titles under the umbrella of “CHW.” Job titles related to the C3 Project¹⁸ recommended CHW roles, and – in order of frequency – included Coordinator, Community Health Representative, Navigator, Educator, Outreach Worker, Case Manager, Advocate, and Assistant/Coach/Consultant. A few titles seemed to refer to other professions. (Data not shown.)

Table 1:

Demographic and Workforce Characteristics of CHW Survey Participants (n = 51) in Oklahoma Responding to the 2019 HRSA Region 6 Training Needs Assessment

Characteristic	Number (%) of Respondents 51 (100.0%)
Gender
Number (%) of respondents	39 (76.5%)
Female	35 (89.7%)
Male or Prefer not to answer	4 (10.3%)
Age Range
Number (%) of respondents	39 (76.5%)
18 – 29	5 (12.8%)
30 – 39	5 (12.8%)
40 – 49	8 (20.5%)
50 – 59	14 (35.9%)
60 – 69	6 (15.4%)
I prefer not to answer	1 (2.6%)
Highest educational attainment
Number (%) of respondents	39 (76.5%)
Associates degree	7 (17.9%)
Bachelors degree	11 (28.2%)
High school or some college	6 (15.4%)
Masters degree/ Doctoral degree/ Medical/ clinical degree	14 (35.9%)
Organization Type
Number (%) of respondents	51 (100.0%)
Tribal health or tribal public health organization (CHRs)	19 (37.3%)
Non-tribal organizations (CHWs)	32 (62.7%)
Level of Experience
Number (%) of respondents	50 (98.0%)
Frontline Worker	42 (84.0%)
Management Level	8 (16.0%)
Geographic Area of Work
Number (%) of respondents	51 (100.0%)
Urban	22 (43.1%)
Rural and Suburban	24 (47.1%)

Roles Played, Skills Used, and Health Issues Addressed by CHRs/CHWs in Oklahoma

Provided with the 10 core roles described in the C3 Project, we asked survey participants to select all roles played by CHRs/CHWs at their organizations to address their clients’ needs. Responses showed that all of these roles were played across the represented organizations. A high percentage of non-tribal CHWs reported their engagement with Participating in evaluation and research, Advocating for individuals and communities, and Providing culturally appropriate health education and information (15/22, 68.2%; 12/19, 63.2%; 23/38, 60.5%, respectively), compared to tribal CHRs reporting on these roles (7/22, 31.8%; 7/19, 36.8%; 15/38, 39.5%, respectively) (Table 2). There was no statistical difference in roles played by CHWs and CHRs (Fisher’s exact = 0.47).

Table 2:

Roles Played, Skills Used, and Health Issues Addressed by CHW Survey Participants (n=51) in Oklahoma Responding to the 2019 HRSA Region 6 Training Needs Assessment

C3 CHW ROLES PLAYED, SKILLS USED, AND HEALTH ISSUES ADDRESSED	CHWs1 n=32 (62.7%)	CHRs2 n=19 (37.3%)	TOTAL n=51 (100.0%)	*P-value, CHWs vs. CHRs
10 CHW roles played
Providing culturally appropriate health education and information n (% of positive responses)	23(60.5%)	15(39.5%)	38(74.5%)	0.47
Conducting outreach n (% of positive responses)	19(57.6%)	14(42.4%)	33(64.7%)	0.47
Care coordination, case management, and system navigation n (% of positive responses)	15(50.0%)	15(50.0%)	30(58.8%)	0.47
Cultural mediation among individuals, communities, and health and social services systems, n (% of positive responses)	17(58.6%)	12(41.4%)	29(56.9%)	0.47
Implementing individual and community assessments n (% of positive responses)	16(55.2%)	13(44.8%)	29(56.9%)	0.47
Building individual community capacity n (% of positive responses)	13(46.4%)	15(53.6%)	28(54.9%)	0.47
Providing direct service n (% of positive responses)	13(46.4%)	15(53.6%)	28(54.9%)	0.47
Providing coaching and social support n (% of positive responses)	12(48.0%)	13(52%)	25(49.0%)	0.47
Participating in evaluation and research n (% of positive responses)	15(68.2%)	7(31.8%)	22(43.1%)	0.47
Advocating for individuals and communities n (% of positive responses)	12(63.2%)	7(36.8%)	19(37.3%)	0.47
11 CHW skills used
Communication skills	32(62.7%)	19(37.3%)	51(100%)	0.37
Professionalism and professional conduct	31(62.0%)	19(38.0%)	50(98.0%)	1.00
Interpersonal relationship-building skills	30(62.5%)	18(37.5%)	48(94.1%)	0.45
Education and facilitation skills	30(62.5%)	18(37.5%)	48(94.1%)	0.86
Individual community assessment skills	31(64.6%)	17(35.4%)	48(94.1%)	0.54
Outreach skills	30(62.5%)	18(37.5%)	48(94.1%)	1.00
Evaluation and research skills	30(63.8%)	17(36.2%)	47(92.2%)	0.03
Advocacy skills	27(58.7%)	19(41.3%)	46(90.2%)	0.33
Service coordination and navigation skills	30(65.2%)	16(34.8%)	46(90.2%)	0.16
Capacity-building skills	26(68.4%)	12(31.6%)	38(74.5%)	0.41
Health issues addressed
Diabetes	13(43.3%)	17(56.7%)	30(58.8%)	0.39
Elder health	4(26.7%)	11(73.3%)	15(29.4%)	.39
Chronic disease prevention	7(58.3%)	5(41.7%)	12(23.5%)	0.39
Maternal and child health	11(100.0%)	0	11(21.6%)	0.39
Mental health	6(60.0%)	4(40.0%)	10(19.6%)	0.39
Alcohol/Substance/Tobacco use	5(50.0%)	5(50.0%)	10(19.6%)	0.39
Cardiovascular disease	7(77.8%)	2(22.2%)	9(17.6%)	0.39
Childhood obesity	8(88.9%)	1(11.1%)	9(17.6%)	0.39
Sexual or reproductive health	8(100.0%)	0	8(15.7%)	0.39
Opioids	5(71.4%)	2(28.6%)	7(13.7%)	0.39
Cancer	3(60.0%)	2(40.0%)	5(9.8%)	0.39
HIV/AIDS	3(75.0%)	1(25.0%)	4(7.8%)	0.39
Adolescent health	2(66.7%)	1(33.3%)	3(5.9%)	0.39
Injury control	1(33.3%)	2(66.7%)	3(5.9%)	0.39
Occupational health	0	1(100%)	1(1.9%)	0.39
Tuberculosis	1(100%)	0	1(1.9%)	0.39

^*P-values were determined by Fisher’s exact test

^**Asthma, Dental Health, and Environmental Health were excluded because of missing data

^***Knowledge base (Health issues addressed (see above) substituted for knowledge base)

¹CHWs: Outside tribal systems

We asked survey participants which of ten C3 Project-recommended skills they used in their organizations how frequently. Overall, among the total workforce, Communication skills (51/51, 100.0%) were utilized most frequently, followed by Interpersonal relationship skills (48/51, 94.1%), and Professionalism and professional conduct (50/51, 98.0%). The skills CHWs used most frequently included Communication skills (32/51, 62.7%); Individual community assessment skills (31/48, 64.6%); Professionalism and professional conduct (31/50, 60.0%); Interpersonal relationship building skills (30/48, 62.5%); Evaluation and research skills (30/47, 63.8%); and Service coordination and navigation skills (30/46, 65.2%). Noticeably, few American Indian CHRs reported using Evaluation and research skills (17/47, 36.2%) (Table 2). No statistically significant differences were found between skills utilized by CHWs and CHRs, except for Evaluation and research skills (Fisher’s exact = 0.03).

To describe the top three health issues that CHRs/CHWs addressed at their organization, survey participants chose up to three responses from a list of 20 choices. Overall, diabetes was selected by the highest percentage (30/51; 58.8%), followed by elder health (15/51; 29.4%), and chronic disease prevention (12/51; 23.5%). Other frequently addressed health issues included maternal and child health (11/51; 21.5%), mental health (10/51; 19.6%), and alcohol/substance/tobacco use (10/51; 19.6%). Only non-tribal CHWs (11/11; 100.0%) reported maternal and child health as a top health issue, while none of the tribal CHRs did. Among those who addressed elder health, the majority (11/15; 73.3%) were CHRs, while few CHWs (4/15; 26.7%) addressed elder health (Table 2). There was no statistical difference between health issues addressed by CHWs and those addressed by CHRs (Fisher’s exact = 0.39).

Current CHR/CHW Trainings and Expressed Training Needs

Using a list derived from a 2014 National Community Health Worker Advocacy Survey,¹⁷ we asked survey participants to select all trainings that were required of CHRs/CHWs in their organization. Each of the nine trainings listed was required by at least one organization. Attendance at workshops (35/51, 68.6%), on the job trainings (32/51, 62.7%), and organization-based trainings (29/51, 56.9%) were required most frequently (Table 3). Comparing required trainings between tribal CHRs and non-tribal CHWs, the trainings reported by CHWs at least twice as frequently included Participating in evaluation and research (10/11, 90.9% CHWs; 1/11, 9.1% CHRs), Conducting outreach (17/25, 68.0% CHWs; 8/25, 32.0% CHRs), and State-based standardized trainings (15/21, 71.4% CHWs; 28.6% CHRs;). There was no statistical difference in required trainings between CHWs and CHRs (Fisher’s exact = 1.00).

Table 3:

Current CHW Trainings and Expressed Training Needs of CHW Survey Participants (n=51) in Oklahoma Responding to the 2019 HRSA Region 6 Training Needs Assessment

CURRENT CHW TRAININGS AND EXPRESSED TRAINING NEEDS	CHWs* n=32 (62.7%)	CHRs** n=19 (37.3%)	Total n=51 (100.0%)	P-Value
Current trainings required of CHWs in their organization
Attendance at workshops	20(57.1%)	15(42.9%)	35(68.6%)	1.00
On-the-job trainings	17(53.1%)	15(46.9%)	32(62.7%)	1.00
Organization-based standardized trainings	17(58.6%)	12(41.4%)	29(56.9%)	1.00
Conducting outreach	17(68.0%)	8(32.0%)	25(49.0%)	1.00
Disease-specific trainings	13(54.2%)	11(45.8%)	24(47.1%)	1.00
State-based standardized trainings	15(71.4%)	6(28.6%)	21(41.2%)	1.00
National standardized trainings (e.g. IHS)	11(61.1%)	7(38.9%)	18(35.3%)	1.00
Implementing individual and community assessments	10(62.5%)	6(37.5%)	16(31.4%)	1.00
Participating in evaluation and research	10(90.9%)	1(9.1%)	11(21.6%)	1.00
Expressed training needs of eight select topics that are HRSA priorities and public health skills
Persuasive communication	22(61.1%)	14(38.9%)	36(70.6%)	0.64
Resource management	18(54.6%)	15(45.4%)	33(64.7%)	0.03
Problem solving	19(59.4%)	13(40.6%)	32(62.7%)	0.45
Policy engagement	20(62.5%)	12(37.5%)	32(62.7%)	0.77
Systems thinking	19(61.3%)	12(38.7%)	31(60.8%)	0.05
Diversity and inclusion	18(58.1%)	13(41.9%)	31(60.8%)	0.89
Change management	16(55.2%)	13(44.8%)	29(56.9%)	0.21
Data analytics	15(51.7%)	14(48.3%)	29(56.9%)	0.16
Expressed training needs of eleven specific health and public health topics
Health education	22(62.9%)	13(37.1%)	35(68.6%)	0.61
Chronic disease	18(56.3%)	14(43.7%)	32(62.7%)	0.20
Mental health	20(62.5%)	12(37.5%)	32(62.7%)	0.86
Other substance abuse	19(59.4%)	13(40.6%)	32(62.7%)	1.00
Opioid abuse	20(64.5%)	11(35.5%)	31(60.8%)	0.16
Childhood obesity	18(60.0%)	12(40.0%)	30(58.8%)	0.36
Communicable disease control	18(60.0%)	12(40.0%)	30(58.8%)	0.72
Injury prevention	16(55.2%)	13(44.8%)	29(56.9%)	0.21
MCH and family health	17(58.6%)	12(41.4%)	29(56.9%)	0.77
Environmental Public Health	15(53.6%)	13(46.4%)	28(54.9%)	0.42
Epidemiology	15(53.6%)	13(46.4%)	28(54.9%)	0.30

^*CHWs: Outside tribal systems

^**CHRs: Mainly tribal

We asked survey respondents whether they would be interested in receiving trainings on eight select topics that were HRSA priorities and public health skills. Most of the 51 CHRs/CHWs participating in the survey expressed interest in these trainings, including Persuasive communication (36/51, 70.6%), Policy engagement (32/51, 62.7%), Resource management (33/51, 64.7%), Problem solving (32/51, 62.7%), Systems thinking (31/51, 60.8%), Diversity and inclusion (31/51, 60.8%), Change management (29/51, 56.9%), and Data analytics (29/51, 56.9%). While over half of the non-tribal CHWs expressed interest for each of these topics, less than half of the tribal CHRs expressed this interest (Table 3). The only statistically significant differences were seen in Systems thinking (Fisher’s exact = 0.05) and Resource management (Fisher’s exact = 0.03).

We asked survey participants about their interests in 11 specific health and public health topic trainings, including HRSA clinical priorities (childhood obesity, opioid abuse, and mental health). The majority of participants expressed interest in receiving trainings in each. Overall, the top five topics of interest included health education (35/51, 68.6%), chronic disease (32/51, 62.7%), mental health (32/51, 62.7%), other substance abuse (32/51, 62.7%), and opioid abuse (31/51, 60.8%). Among the non-tribal CHWs, the top five topics of interest were opioid abuse (20/31, 64.5%), health education (22/35, 62.9%), mental health (20/32, 62.5%), childhood obesity (18/30, 60.0%), and communicable disease (18/30, 60.0%). Among the tribal CHRs, the top five topics of interest were environmental public health (13/28, 46.4%), epidemiology (13/28, 46.4%), injury prevention (13/29, 44.8%), chronic disease (14/32, 43.7%), MCH/family health (12/29, 41.4%) (Table 3). There was no significant statistical difference between CHWs and CHRs in terms of specific topics of interest.

In response to one open-ended follow-up question, 16 out of 51 respondents suggested other training topics not listed in the survey. These topics can be grouped into professional skills; meeting resource needs; women, infants, and children; senior or elder health; and violence prevention/care. Other topics mentioned included men’s health, culture-related topics, workplace wellness and policies, medical marijuana, and behavioral change.

Training Delivery Logistics, and Barriers and Facilitators to Professional Development

Survey participants were asked how likely they would be to use public health workforce development trainings with specific delivery methods. The majority of respondents indicated multiple delivery formats that they would participate in including in-person classes (78.1%), online classes accessible on demand (78.1%), blended learning (online-on-demand and real-time learning) (75.6%), and live webinar (69.0%). Fewer participants responded that they would use podcasts (45.0%) as a training delivery format (Figure 1). No statistically significant differences were observed between CHWs and CHRs.

Figure 1:

Training Delivery Methods of Interest to CHW Survey Participants (n = 51) in Oklahoma Responding to the 2019 HRSA Region 6 Training Needs Assessment

Asked about the need for trainings to be delivered in a language other than English, few participants responded ‘Yes’ (7/39, 17.9%), with the top three languages mentioned being Spanish (5/7, 71.4%), Muscogee Creek (1/7, 14.3%) and Marshallese (1/7, 14.3%). (Data not shown.)

Choosing from among five provided responses, the major barriers to CHRs/CHWs training included financial support (30/51, 58.8%), time (25/51, 45.1%) and employer’s approval/support (25/51, 45.1%) (Table 4).

Table 4:

Barrier and Facilitators to Professional Development According to CHR/CHW Survey Participants (n = 51) in Oklahoma Responding to the 2019 HRSA Region 6 Training Needs Assessment

BARRIERS AND FACILITATORS TO PROFESSIONAL DEVELOPMENT	Respondents			P Value
	CHWs* n=32 (62.7%)	CHRs* n=19 (37.3%)	Total n=51 (100.0%)
BARRIERS TO PROFESSIONAL DEVELOPMENT
Financial Support	20(66.7%)	10(33.3%)	30(58.8%)	n/a
Employer Approval/Support	14(60.9%)	9(39.1%)	23(45.1%)	n/a
Time	14(56.0%)	11(44.0%)	25(45.1%)	n/a
Accessible	7(58.3%)	5(41.7%)	12(23.5%)	n/a
Technology	5(100.0%)	0	5(9.80%)	n/a
FACILITATORS TO PROFESSIONAL DEVELOPMENT
Free courses	23(67.6%)	11(32.4%)	34(66.7%)	n/a
Personal interest in the topic	20(66.7%)	10(33.3%)	30(58.8%)	n/a
Schedule flexibility	16(59.3%)	11(40.7%)	27(52.9%)	n/a
Belief that it will improve my professional skill set	15(57.7%)	11(42.3%)	26(50.9%)	n/a
Approval from employer to take course during work hours	16(61.5%)	10(38.5%)	26(50.9%)	n/a
Availability of completion documentation (certificate)	12(54.5%)	10(45.5%)	22(43.1%)	n/a
Financial support from my employer	13(61.9%)	8(38.1%)	21(41.2%)	n/a
Flexibility in technology required to access online courses	12(63.2%)	7(36.8%)	19(37.3%)	n/a
Continuing education credits available	9(60.0%)	6(40.0%)	15(29.4%)	n/a

^*CHWs: Outside tribal systems

^**CHRs: Mainly tribal

Asked to choose from among nine provided responses, the top five facilitators for public health professional workforce development were free courses (34/51, 66.7%), personal interest in the topic (30/51, 58.8%), schedule flexibility (27/51, 52.9%), employer’s approval (26/51, 50.9%), and the belief that the training will improve the professional skill set (26/51, 50.9%) (Table 4). About half (51.3%) of total respondents indicated that their employer provided both financial assistance and allowed them to take courses during work hours. (Data not shown.)

DISCUSSION

Previous national surveys distributed to Oklahoma were not able to capture information on CHRs/CHWs, as respondent numbers were too small.¹⁷ This study demonstrated that organizations collaborating within the state to distribute a multi-state survey to their in-state networks could lead to response rates allowing for descriptive analysis. Our survey data provided a preliminary snapshot of Oklahoma’s CHR/CHW workforce characteristics, trainings received, trainings needed, and preferred training delivery formats. This data can serve as starting point to understand and support CHR/CHW trainings in Oklahoma in the context of a national workforce.

In our survey, most CHRs/CHWs were female, and had a wide range of educational attainment, which falls within national workforce characteristics.²¹ Since more than half of CHRs/CHWs were close to retirement, recruiting new CHRs/CHWs seems important. The majority of respondents identified as “frontline public health workers,” supporting the American Public Health Association’s definition of CHWs.¹¹ CHRs worked at tribal health or public health organizations, primarily in rural areas. This makes sense considering the geographic location of American Indian Tribes and Nations within the rural state of Oklahoma.^22,23 CHWs primarily worked in urban areas, with the majority employed by state and local health departments, and community-based organizations. Some CHWs were employed by non-profit organizations, federal health agencies, and hospitals/other health care providers. Our findings contrasted with a 2010 national survey²¹ according to which CHWs primarily worked for non-profit/Grassroots organizations, community health centers/community-based clinics, and clinics/hospitals. In Oklahoma, health departments led the way.¹² The low representation of community health centers (CHCs) in our sample may be due to the sample selection, but may also be related to funding issues. While the Affordable Health Care Act had created new payment options for CHCs through Medicaid,²⁴ this survey was conducted before Oklahoma voters approved Medicaid expansion in 2020.^25,26 Mirroring the national diversity of CHW titles,^18,27 survey respondents provided diverse job titles under the umbrella term of “CHW,” however, some titles referred to other professions. In the absence of an established CHW workforce, it is likely that respondents self-identified as CHWs based on roles and activities similar to those of CHWs.

The recent C3 Project ¹⁸ built national consensus among CHW (used as an umbrella term and including CHR) networks and stakeholders to recommend core roles and skills. In our survey, CHRs/CHWs across the represented organizations in Oklahoma engaged in all of the recommended core roles and skills. This finding supports the need to follow C3 Project recommendations to train CHRs/CHWs in all recommended skills, as each skill applies to multiple roles. Importantly, training CHRs/CHWs on the broad scope of core roles and skills increases their employability. Our findings showed that some CHRs and CHWs played some roles more than others. These differences, however, were not statistically significant, with the exception of Evaluation and research skills. This difference seems related to organizational needs, locality, or ethnic group preference. American Indian Tribes and Nations may not support “research” conducted by outsiders due to past negative experiences.²⁸ Our insights into core skills used by CHWs in Oklahoma are important, because skills are trainable workforce competencies. To address “knowledge base,” a core CHW skill, we asked survey participants about the top health issues they addressed, which included diabetes, elder health, chronic disease prevention, maternal and child health, mental health, and alcohol/substance/tobacco use. CHW contributions to changing health behavior^7,8 and reducing chronic disease health disparities are documented abundantly.^8,9 Oklahoma needs a welltrained CHW workforce to help improve peoples’ lives, and reduce costs and health disparities through locally and culturally relevant programs. Since CHRs mostly focused on elder health, and CHWs focused on maternal and child health, some of the future trainings should be geared to address specific needs. We conducted this survey prior to the COVID-19 pandemic, however, it is reasonable to propose that CHRs/CHWs should receive training related to addressing COVID-19 to help increase the effectiveness of community prevention and care in hard-hit minority communities.^29–31

Our data captured a patchwork of trainings currently required of CHRs/CHWs by their organizations. Each of the nine trainings listed was required by at least one organization. Attendance at workshops, on the job trainings, and organization-based trainings were the most common formats. In the absence of a standardized training or guidelines offered for CHWs outside the tribal systems in Oklahoma, organizations tailored CHW trainings to their current job descriptions. While this practice makes sense from organizational perspectives, and reflects common practice across the nation,²¹ it does not support CHWs as a workforce. Current training practices do not provide room for the workforce self-determination that is “needed to ensure the integrity of CHW practice and professional values as defined by CHWs themselves.”³² While CHRs were required to take the national Indian Health Service training, it was unclear as to why less than half of the CHRs reported having taken this training. All CHRs/CHWs expressed interest in receiving additional trainings, including HRSA priorities and public health skills. Endorsed training interests confirmed CHRs/CHWs as “frontline public health workers.” The open-ended question confirmed the CHR/CHW current focus on elder and maternal and child health, raised new topics such as violence and men’s health, and elicited a CHR/CHW workforce specialty, i.e. addressing social determinants of health by linking clients to needed clinical and social resources. Overall, current trainings and training interests in Oklahoma fell within the core roles and skills of CHWs as recommended at the national level. While neither the C3 Project¹⁸ nor the National Association of Community Health Workers³³ recommend required trainings, they advocate for trainings to follow the C3 Project recommendations to build a broadly trained workforce. Current developments in Oklahoma seem to move into this direction, as CHRs/CHWs and their allies across the state are collaborating, and developing foundational and disease specific trainings.

The majority of respondents was interested in multiple delivery formats, including in-person, virtual, and blended learning. The finding that few respondents thought trainings should be in languages other than English needs reexamination, because Oklahoma’s communities and languages are diverse.³⁴ Major barriers and facilitators to trainings included financial support, time, and employer support. About half of the respondents thought their employers provided both financial assistance and time during work hours. Respondents felt incentivized by personal interest in the topic and a belief in training effectiveness. Until Oklahoma-based trainings are fully implemented, CHRs/CHWs and their employers can tap into available online trainings.

The modest sample size of this study limits its generalizability, yet, it offers the first, detailed characterization of Oklahoma’s CHR/CHW workforce. Another limitation of this study is that respondents self-identified as CHWs in the absence of a well-defined CHW workforce, which points to the need for continued efforts into this direction. Conclusions on training needs are somewhat limited by responses offered in the survey, but additional qualitative data mediated this limitation. The survey did not ask about social determinants of health (SDOH),⁵ one of the most important health issues addressed successfully by CHRs/CHWs,^5,6 although we received some indication of its importance. Future workforce projects focused on CHRs/CHWs in Oklahoma need to inquire about training needs on SDOH. Finally, our survey was conducted prior to the COVID-19 pandemic and did not capture likely changes in training needs, training delivery methods, and barriers and facilitators to professional development. A follow-up survey to inquire about pandemic-induced changes in training needs is advisable.

CONCLUSIONS

As the OPHTC and partners develop trainings, it will be important to continue collaboration with CHRs/CHWs and employing organizations to confirm training needs, and develop and implement meaningful trainings. As CHWs outside tribal systems are gaining momentum and tribal CHRs may benefit from additional support, efforts to build a state-wide, well-trained workforce will require data, standardized trainings, continued education, funding, collaboration, and supportive policies. While some of this is in process in Oklahoma, improving the availability of workforce-specific trainings will be key for CHRs/CHWs

HUMAN PARTICIPANT COMPLIANCE STATEMENT.

The Region 6 South Central Public Health Training Center’s (R6SCPHTC) training-related needs assessment data collection is considered to have exempt status by Tulane University’s Institutional Review Board (IRB). The R6SCPHTC shared the Oklahoma-relevant data described in this paper under a data sharing and usage agreement with the Oklahoma Public Health Training Center at the University of Oklahoma Health Sciences Center’s Hudson College of Public Health. The objective of our present analysis is to document the current and unmet education and training needs in Oklahoma’s Community Health Representative (CHR) / Community Health Worker (CHW) workforce in order to guide future programming. All activities leading to this paper fall under the R6SCPHTC umbrella determination.