Mounting Evidence of the Effectiveness and Versatility of Community Health Workers

In December 2011, the American Journal of Public Health dedicated a theme issue to community health workers (CHWs) when studies of the effectiveness of CHWs in health improvement were just beginning to appear in peer-reviewed journals. The related “Editor’s Choice” stressed that proper evidence and cost-effectiveness assessment was needed to gain reimbursable institutional support for these services.1 We take the opportunity of two articles dedicated to CHW in this issue of AJPH2,3 to review the situation four intervening years later. CHWs, also referred to as health workers, health navigators, promotores, and various other titles, play a variety of roles within both research and patient-centered care teams including fostering linkages with local communities, data collection, outreach and case management, counseling and education, and health system navigation. Community-based research can benefit from the insights of CHWs regarding acceptability, validity and feasibility, and potential barriers to implementation. As a member of a research team, a CHW also provides a unique perspective in interpretation of findings. Of note, CHWs are increasingly involved in public health interventions that identify and address barriers to prevention, care, and treatment. As members of their local communities, CHWs can help programs create culturally responsive public health interventions, as well as community-based research studies that are informed by and responsive to local priorities and concerns. An indubitable recognition of the success of CHW is that more states each year have been developing laws, regulations, or both addressing issues of training, credentialing, and reimbursement of CHWs. The objective is ensuring the effectiveness of this component of the workforce and retaining CHWs in the field through support of sustainable financing mechanisms.4 However, the ongoing struggle in the United States to reign in health care costs has placed CHWs in a critical but uncertain position. Are they exceptionally cost-effective team members who can improve outcomes at a low cost? Or are they yet another layer of staffing in an already bloated system characterized by inefficiencies, redundancies and misaligned incentives? With a stretched and stressed healthcare work force and an impetus to add workers who are reflective of the communities they serve, there is substantial support for the first view.