A History of the Center For Sustainable Health Outreach

The first University of Southern Mississippi-based Co-director of CSHO, Agnes Hinton, first began working with development of community health worker programs in 1987.  Freedom from Hunger (FFH), a nonprofit organization based in Davis, California, approached health and human services staff in several southern states, including Mississippi, about their interest in working with FFH to develop programs to address nutrition and health problems.  This feasibility exploration was based upon a study commissioned by FFH, “The Geography of American Poverty.”  The study concluded that the Mississippi Delta had one of the largest concentrations of rural counties in which high poverty levels combined with poor health and lack of access to adequate health care caused suffering for at-risk population groups like women, children and the elderly.  The study also found several barriers to existing service-providing agencies that often prevented them from having an impact on the health problems in the community.  Insufficient funding, lack of integration and coordination of services, and little community awareness of services all contributed to the poor health in the Delta.  Based upon enthusiastic responses from state leaders, Mississippi was selected as the program site.  In 1988, Partners for Improved Nutrition and Hunger (PINAH) was established in the Mississippi Delta as a collaboration among Freedom from Hunger, the Mississippi State Department of Health and the Mississippi Cooperative Extension Services.  A fundamental aspect of PINAH was to build partnerships between a community and the local service agencies.  Under the PINAH umbrella, two pilot programs were begun:  the Community Health Advisor program, led by the State Department of Health, and Partners for Life, a WIC/EFNEP initiative led by the Cooperative Extension Services.

The Community Health Advisor program is based on the premise that natural helpers exist in every community who could be mobilized to address health problems.  Natural helpers are trusted persons in a community that others go to for advice, assistance, or help in resolving personal or family needs.  The program was designed to identify and train these volunteers called Community Health Advisors (CHAs) to address health related issues. 

After five years in one area, Humphreys County, in the Mississippi Delta, an evaluation study completed by experts from the University of North Carolina, Chapel Hill, documented the effectiveness of the PINAH program.  They confirmed the idea that the best and most effective solutions to problems come from the people affected.

…PINAH’s bold and innovative approach to community health promotion demonstrates that a partnership based on community empowerment can establish the necessary conditions for community development and good health status.  Evidence from four years of evaluation showed clear and remarkable impact on project communities’ competence to solve problems as an equal partner with agencies. Strong evidence showed an impact of Community Health Advisors (CHAs) on the service delivery system’s capacity to coordinate and collaborate on responses to community needs.

 The evaluation studied the program’s impact at three levels:              

In each level, improvement was significant and proved that the Community Health Advisor program was successful in that it empowered communities to identify and solve its own problems.  Statistics for Humphreys County for 1991-1995, revealed that the infant mortality rate decreased by 60%, percentage of births to single teens decreased by 18%, while high school graduation rates increased by 20%. Community activities sponsored by CHAs and other sponsors increased from 3 in 1989 to 21 in 1992.  Referrals to community health and social services rose from one per week per CHA in 1989 to two per week per CHA in 1992.

As of April 1993, 114 Community Health Advisors had been trained and were actively addressing the needs in their communities in seven Delta counties.  By 2000, there were ten active Community Health Advisor groups in the Mississippi Delta, each with an average of 17 CHAs.  Activities sponsored by the groups include a food pantry, Helping Hands of Humphreys County, and a landscaped, asphalt walking track in Sunflower County.

In 1993, Freedom from Hunger created the Community Health Advisor Network (CHAN) in response to broad-based interest from a variety of health organizations regarding the program.  An office was established in Jackson, Mississippi, and Agnes Hinton was named CHAN director. CHAN promotes and supports Community Health Advisor programs by providing information, training, technical assistance, and linkage to sponsoring organizations.  CHAN development work continued in the Delta, and the program expanded to Alabama, Arkansas, and Georgia.

In 1996, after receiving her doctorate degree from the University of Alabama at Birmingham, Agnes Hinton joined the faculty of The University of Southern Mississippi (USM) in Hattiesburg and brought the Community Health Advisor Network with her. From USM, the Community Health Advisor program was established in Texas; Delaware; and Chicago, Illinois; with growth continuing in the Mississippi Delta and technical support given to ongoing programs in other states. CHAN staff members have trained implementing organizations from Delaware, Louisiana, Maryland, the Virgin Islands, and other parts of Mississippi. 

In 1994 the W. K. Kellogg Foundation (Kellogg) asked the Center for Policy Alternatives (CPA) to determine how their grantees could be financially sustained after Kellogg funding ceased.  CPA requested that the Harrison Institute at Georgetown University Law Center plan and implement the Kellogg project.  The Harrison Institute team was asked to analyze 35 Kellogg grantees across the nation to find if there were any common elements that would lead to sustainable funding.  They saw that a large majority of programs used community health workers (CHWs) and that CHWs were an integral and necessary component to the health care system.  CHWs increased the proper usage of health care providers, which can lead to monetary savings.

The Harrison Institute’s report to Kellogg stressed that services provided by CHWs were the common ground around which Kellogg grantees could develop a strategy to promote sustainable funding.  Programs that have CHWs can compete in the market place, receive Medicaid money and receive funding from a variety of alternative sources.  In some cases creating alternative funding may require policy changes on the local, state or federal level.  The Harrison Institute’s work for the Kellogg Foundation explored a number of potential federal funding options for CHW programs, and a leadership brief, “Community Health Workers:  A Leadership Brief on Preventive Health Programs,” (November 1998) was produced.  The brief introduced a menu of these funding options along with an introduction to the role that CHWs play and a survey of best practices in different regions of the country.

Shortly after the Harrison Institute released its leadership brief, the Annie E. Casey Foundation (Casey) issued its National Community Health Advisor (CHA) Study, which was based on several years of research by a team of researchers and practitioners.  Based on our track record and relationships with these practitioners, Casey commissioned the Harrison Institute to prepare a summary of the study for national dissemination to community health programs and policy makers.  The Casey report made it clear that CHAs needed a national organization to support training, evaluation, policy development and general technical assistance.  The Harrison Institute looked for a partner that could provide training and evaluation to complement the Harrison Institute’s work on policy development and technical assistance.  It was clear that The University of Southern Mississippi’s Community Health Advisor Network would be the perfect partner, and in 1998, Agnes Hinton and Jason Newman from the Harrison Institute began discussing their universities partnering to support CHWs, and developed a concept paper that was discussed with Mississippi Congressional staff.

In 1999, through a grant from the Health Resources and Services Administration Office of Rural Health Policy, a collaborative relationship was developed between The University of Southern Mississippi and the Harrison Institute for Public Law at Georgetown University Law Center to form the Center for Sustainable Health Outreach (CSHO).  CSHO provides support and technical assistance to CHWs and CHW programs in the following areas:  program development and support; program funding and sustainability strategies; public policy development; strategic planning assistance; program evaluation; and education and training. CSHO also assists CHWs and CHW programs by facilitating partnerships with funders, policy makers, health systems, and community organizations.  CSHO serves as a national point of contact for CHWs and CHW programs and provides them with reliable, up-to-date information on emerging trends in the field.

The USM staff of CSHO is responsible for the education, training and evaluation functions of the Center. CHAN is one program of the Center that trains and supports Community Health Advisors, one specific type of community health worker.  The Maternal/Infant Health Outreach Worker Program (MIHOW), a peer home visitation program for pregnant women and mothers of children birth to three years developed by Vanderbilt University, is another model CHW program that CSHO-USM promotes in Mississippi, Arkansas, Tennessee, and Louisiana.  The Deep South Network for Cancer Control, which utilizes an adaptation of the CHA model to focus on cancer awareness and control in Mississippi and Alabama, is another model CSHO program. 

The Harrison Institute for Public Law arm of CSHO (CSHO-Georgetown) is responsible for policy development and sustainability information.  Building on a request for technical assistance from programs in Virginia, CSHO-Georgetown was able to help a coalition of programs obtain funding for a state center based at the Blue Ridge Area Health Education Center to provide statewide support to CHW programs.  The new center, named the Virginia Center for Health Outreach (VCHO), is the first of its kind on the state level.  CSHO-Georgetown provides technical assistance to VCHO in the areas of sustainability and policy development.  CSHO-Georgetown is currently researching issues of CHW liability, incorporating a state CHW coalition, and past legislative initiatives that may assist in CHW policy development in Virginia.

 Together, the two groups that comprise CSHO form a resource umbrella for CHW programs nationwide.