摘要：Community health workers (CHWs) have gained increased visibility in the United States. We discuss how to strengthen the roles of CHWs to enable them to become collaborative leaders in dramatically changing health care from “sickness care” systems to systems that provide comprehensive care for individuals and families and supports community and tribal wellness. We recommend drawing on the full spectrum of CHWs’ roles so that they can make optimal contributions to health systems and the building of community capacity for health and wellness. We also urge that CHWs be integrated into ”community health teams” as part of “medical homes” and that evaluation frameworks be improved to better measure community wellness and systems change. The United States is currently embarking on a new era of social change to improve the well-being of its residents. Improvements are needed to remediate a health care system whose costs have spiraled out of control 1 while still leaving about 50 million citizens without health care coverage, 2 a system that has lagged behind its counterparts in other industrialized nations in terms of health outcomes and the efficient delivery of quality health care services. 3 , 4 A new era of ethics, efficiency, and effectiveness is needed to make health care systems more accessible, affordable, and accountable for all Americans. 4 , 5 Unfortunately, current relationships in the United States between its people, their communities, and the health care system can often be described as disconnected, and the care rendered is often episodic. If true changes in health care systems are to come about, and if people are going to become more engaged in these systems and in improving their own health, then these relationships must become more trusting and more continuous, and they should be mutually respectful. For more than 60 years, community health workers (CHWs) have been working to improve engagement between communities and the US health care system, but mainly on short-term, grant-funded projects and in grassroots volunteer community initiatives. 6 Increasing awareness of the contributions of CHWs, combined with changes in health care systems, however, should increase their involvement with health care providers and community and tribal members in the years to come. CHWs are recognized as important members of the public health and primary health care workforce. 5 , 7 In 2009, the American Public Health Association defined CHWs as frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison … between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. 7 To date, CHWs have shown their effectiveness in high-priority health care issues such as managing chronic diseases, improving birth outcomes, and maintaining child wellness. 7 – 18 CHWs can play multiple roles, including improving access and continuity of health insurance coverage, enhancing provider–patient communication, monitoring of health status, monitoring adherence to treatment, and linking to health and human services. 7 – 18 Broader recognition of the CHW as a distinct occupation will no doubt help these workers expand their contributions, and thus the inclusion of CHW as a Standard Occupational Category (SOC) in 2009 was an important step. In 2010, CHWs were recognized by the Department of Labor with their own SOC (#21–1094). 19 Also in the recent past, the States of Texas, Massachusetts, Ohio, and Minnesota have taken actions that give official recognition to the job category of CHW. More broadly, a growing consensus, which includes the Institute of Medicine, 20 , 21 has called for greater roles for CHWs in improving access to care, controlling costs, and helping to eliminate persistent health inequities among vulnerable populations, as well as including CHWs within multidisciplinary care teams. With the fundamental changes currently seen in public health and the financing and delivery of health care services, we now have an opportunity to work toward shifting current health care systems to ones with a patient-centered perspective and a preventive approach in which CHWs, as members of community health teams, can help to create systems that are actually seen as more appropriate and accessible by community members and society at large. In this Commentary, we reflect on the philosophy in public health prevention of viewing the well-being of populations as an ethical issue, a philosophy that prioritizes benefits to the community. We propose 3 action steps involving CHWs to further drive this philosophy 7 : Promote the awareness and appreciation of the uniqueness of CHWs and support their roles in bringing community perspectives and priorities into the process of improving health care systems; Promote the integration of CHWs in the full range of health care delivery and population health programs; and Implement a national agenda for CHW evaluation research and develop comprehensive polices to enhance the sustainability of the CHW workforce, with CHW leadership in guiding policy recommendations.
