摘要：Community health workers (CHWs) are increasingly being incorporated into health programs because they are assumed to effectively deliver health messages in a culturally relevant manner to disenfranchised communities. Nevertheless, the role of CHWs—who they are, what they do, and how they do it—is tremendously varied. This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs, and translating research into practice. We discuss some of these challenges and provide examples from our experience working with CHWs. We call for future research to identify the “core elements” of effective CHW programs that improve the health and well-being of disenfranchised communities. THERE SEEMS TO BE A CON sensus: Community health workers (CHWs) are a good idea. They are a cost-effective way to promote health and provide some health care services to disenfranchised communities. Furthermore, because most CHWs are members of the communities within which they work, they are assumed to deliver health messages in a culturally relevant manner. 1–4 Systematic literature reviews of CHW programs worldwide have provided evidence of their effectiveness for certain behaviors and disease categories, but evidence is still insufficient to justify general recommendations for policy and practice. 4–8 Although community educators and healers have existed worldwide for centuries, CHWs, defined as laypersons who serve as liaisons between members of their communities and health care providers and services, have played a formal role in health care since the 1940s. 6,9 Over time, health program planners’ efforts to collaborate with CHWs have waxed and waned because of factors such as economic need or health care labor shortages. 9,10 Yet, in the United States since the 1980s, health program planners have increasingly collaborated with CHWs to deliver various types of health promotion programs. 9,11 With this increase, it has become undoubtedly clear that the role of CHWs today—who they are, what they do, and how they do it—is tremendously varied. 10 This variability presents a number of challenges for conducting research to determine the effectiveness of CHW programs and to translate that research and evidence into practice. To ensure that planners integrate CHWs into programs effectively, researchers must seek clarity about the following issues: What problems arise because of the variability surrounding who CHWs are and what they do? How can we evaluate CHW programs to better document their effectiveness? And, ultimately, how can we elucidate the core elements of CHW programs so that effective programs can be adopted and implemented in other settings? We explore these issues and provide some examples from our firsthand experience as academic researchers who collaborate primarily with promotores (CHWs for Latino populations). Community health workers are described by using several different terms, including lay health advisors, patient navigators, promotores , outreach workers, peer leaders, peer educators, and community health advocates. The diversity of names reflects the different types of roles, or even opposing roles, CHWs are expected to play. For example, the word “lay” in “lay health advisors” suggests that CHWs are not “professionals,” nor have they acquired “expert” knowledge that would set them apart from an ordinary person. The term “patient navigators” implies that the CHWs are embedded within a health care system to the extent that they can help link patients to appropriate care. “Peer leaders” suggests that there is a commonality between the CHWs and their clients, and that they have some leadership characteristics that motivate community members to model or adhere to their recommendations. The term “health advocate” implies that CHWs play an activist role within their community and that their work is related to the larger struggle for social justice for disenfranchised communities. The differences in roles implied by these terms are more than simple semantics; they imply skills and training that would likely vary considerably.
