Community Health Workers (CHWs), Extension Agents, and Health Literacy Community Advocates

In rural areas, community health workers (CHWs), extension agents, or other types of health literacy community advocates can work within various settings to support programs designed to improve personal health literacy. CHWs, or promotoras, are trusted members of the community that work directly with other community members to help them adopt healthy behaviors. Specific services CHWs may provide include:

Assisting with healthcare access
Improving specific skills related to health literacy
Providing education
Making at-home visits to help people manage their health, including taking medication and understanding chronic conditions
Offering interpretation services and other culturally appropriate services

In rural areas, CHWs can be an important asset to a program as they mirror the culture, language, and experience of a community. Rural CHW programs have shown promise in helping people understand health materials, learn how to manage chronic diseases, and navigate the healthcare system.

Health extension agents are health workers with a variety of credentials who serve as health educators and trusted sources of information within a community. Extension agents focus on a specific scope of health, such as nutrition, and are experts in their field. They provide education to improve health literacy and link communities with resources to address social determinants of health. Health extension agents may provide resources and educational materials to help communities make more informed healthcare decisions on topics such as:

Disease prevention and management
Reading nutrition information and ingredients on food labels
Local resources to help answer specific medical questions and concerns
Health insurance and other financial decisions

Health literacy advocates help bridge the gap for individuals with limited health literacy by assisting in understanding written health communication. Any community member can serve as a health literacy advocate, including public health officials, community members, healthcare providers, and other organizational leaders.

For more information about implementing programs that use CHWs to improve health outcomes in rural communities, see the Community Health Workers Toolkit.

Examples of Programs Using CHWs, Health Extension Agents, and Health Literacy Community Advocates to Improve Health Literacy

Messengers for Health is a nonprofit organization on the Apsaalooke (Crow) Reservation in Montana that conducts health outreach and education to build community capacity and improve the health and well-being of people living on the reservation. Crow people are trained as community advocates, known as Messengers, who help educate family, friends, and neighbors about the importance of disease prevention and management. The program began as an effort to improve cervical cancer screening rates for Crow women. As a result of the program, cancer screening and prevention are more commonly talked about in the Crow community and women have been more willing to connect with needed healthcare services. All materials and resources developed for health education are culturally tailored for people on the Crow Reservation. The Messengers for Health program has expanded to focus on both men's and women's health promotion and disease prevention topics.
The University of Arkansas for Medical Sciences (UAMS) Center for Health Literacy employs cooperative extension agents and health professionals who work to improve the health of individuals and populations by making health information easy to understand and use. Extension agents use the How to Talk to Your Doctor HANDbook, available in English and Spanish, developed by the Center. In addition, the University Cooperative Extension Service leads the Extension Wellness Ambassador Program through which health extension agents educate and train community members on strategies for improving health literacy and overall health and well-being, including healthy eating, importance of exercise, chronic disease prevention, and other topics.
The Florida Literacy Coalition developed a health literacy curriculum that has been used throughout Florida, including rural parts of the state, to improve health literacy among Floridians. The coalition uses CHWs to conduct trainings for teachers and tutors, using the nationally recognized Staying Healthy curriculum. The curriculum is written at a 4th-5th grade reading level so it is suitable for all learners, including people who are learning English as a second language. The curriculum helps student understanding of health information by using activities, prompts, and cultural differences when talking about general health topics.

Program Clearinghouse Examples

Doña Ana County Health and Human Services Department has a program that uses CHWs/promotoras to educate residents about the COVID-19 pandemic and the importance of vaccination.
Cornerstone Care, Inc. is working with local hospitals in southwestern Pennsylvania and northern West Virginia to train CHWs on the CATCH curriculum and conduct outreach to residents. The CATCH curriculum improves health literacy by teaching students and staff about active living and nutrition.
Purchase District Health Literacy Initiative has a program that works with CHWs to improve health literacy among patients by helping with medication adherence, hospital discharge instructions, and disease management.
Lake Okeechobee Rural Health Network, Inc. (LORHN) is implementing a variety of programming and training in the community using CHWs.

Implementation Considerations

Many CHWs, extension agents, and other health literacy community advocates may require additional training. This includes training on specific diseases and health concerns as well as specific skills and techniques for improving health literacy. Programs should consider the need for training to ensure CHWs and advocates are prepared to implement strategies involved in the intervention. When developing health literacy program materials, it is also important they are adapted to a level of understanding suitable for both the consumer and the CHW, extension agent, or other community advocate, who often do not have clinical or medical experience. In addition, programs that use CHWs in healthcare settings should be aware of certification requirements and whether reimbursement for CHW services is possible.

For more information about implementation considerations for health literacy programs planning to use CHWs, extension agents, or other community advocates, see the Social Determinants of Health in Rural Communities Toolkit.

Resources to Learn More

Building a Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs
Document
Provides information for developing CHW programs and offers recommendations and policy guidelines derived from hospital and health systems, federal and state agencies, academic institutions, and community-based organizations. Covers best practices, credentialing, funding sources, and strategies for sustainability.
Author(s): Brooks, B.A., Davis, S., Frank-Lightfoot, L., et al.
Organization(s): American Hospital Association (AHA), National Urban League
Date: 7/2018

Cooperative Extension and Health Literacy: A National Focus
Document
Discusses the significance of incorporating health literacy practices and related educational materials into existing community extension programs.
Author(s): Koukel, S., Newkirk, C., Bercaw, S., Letto, B., & Malekian, F.
Citation: Journal of Human Sciences and Extension, 6 (2), 71-80
Date: 2018

A Review and Report of Community-Based Health Literacy Interventions
Document
Literature review identifying community-based interventions involving different settings, topics, and outcomes that were implemented to change health literacy behaviors, status, and skills.
Author(s): Baur, C., Martinez, L.M., Tchangalova, N., & Rubin, D.
Organization(s): National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Roundtable on Health Literacy
Date: 3/2017