Roles and Functions of Community Health Workers in Primary Care

I write to offer several comments, starting with an objection over one specific finding in an otherwise well-written and useful work.

1. "CHW-PCs" (a term coined for the purposes of this paper) are described as having "little or no formal medical education," yet the authors include a specific category of roles in provision of clinical services which otherwise would require licensure. The example offered is that of the Alaska Community Health "Aid" [sic], which is commonly mistaken for a CHW. In fact, the State of Alaska does NOT recognize Community Health Aides (CHAs) as CHWs, and is engaged in concerted efforts to develop a separate CHW workforce, including an apprenticeship program operated by the Alaska Primary Care Association. I have confirmed this in direct contact with State and PCA officials. CHAs do receive substantial clinical training; one source of confusion is that they are (wisely) chosen for this role by the members of the villages they serve, which is similar to the foundational element of the definition of the CHW, namely that they should be "of" or "from" that community. They do offer preventive education, but they are viewed by the health care system more as midlevel providers than as CHWs.

2. The authors acknowledge that CHWs have been "particularly effective" when they share key characteristics with the population served, but in fact there is scant evidence of the CHW "model" being applied at all outside low-income communities and communities of color. Historically, CHWs in the U.S. were first recognized at the federal level in anti-poverty policies of the 1960s, and the Indian Health Service's Community Health Representative (CHR) Program survives as the largest single federally-funded CHW program today. "Patient navigators" and "health coaches" can be effective in certain assistance to other populations, but they generally do not operate on a "peer support" basis as CHWs do, nor do they operate in as broad a range of roles as CHWs do.

3. CHWs still face challenges in gaining acceptance, as the authors correctly emphasize. These challenges partly arise because officials in health care tend to think in clinical terms. CHWs have been at pains to clarify their primarily non-clinical practice, emphasizing that they cannot perform any duties that require a clinical license. They also generally resist efforts to add clinical duties to their roles. The growing recognition of the importance of social determinants has been helpful in justifying inclusion of CHWs in clinical teams for non-clinical reasons. But perhaps more importantly, it has also been challenging to explain a practice which is RELATIONAL rather than TRANSACTIONAL in nature. As new care structures demand of providers the capability to establish relationships and trust with their low-income patients, as well as maintain more candid and continuous communication with them, the value of relationship-based professionals (CHWs) can only increase.

Competing interests: None declared