In an era of intense concern about the high costs of health care, the increased numbers of people who are obese or have chronic illnesses, and the many people who have either no health insurance or inadequate coverage, it seems only logical that lay community health workers (CHWs) can play an important role in health care. The concept of having lay people in the community serve as integral health care team members is not a new one. Interestingly, the role of lay CHWs can be traced to the 1940s in the People's Republic of China with the introduction of the "barefoot" doctors who were tasked with providing medical treatment and education to people who lived in rural areas. Similarly, in the 1980s, I met with lay CHWs in the urban ghetto in Bangkok, Thailand, who provided indispensable health services in collaboration with public health nurses to residents of their community. In the United States in the 1970s, a key aspect of the planning for the least restrictive agenda in mental health care was to move patients out of the large hospitals and back into their home communities where their care would be provided by both professionals and lay CHWs.
Clearly, we are seeing a resurgence of interest and commitment to the engagement of lay CHWs. 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.",1 It seems easy to understand how members of a community could benefit from having someone who lives in their community, understands their customs and language, and whom they trust assist them in maintaining or attaining health. However, too often in the United States, funding for CHWs has been part of a demonstration project that was funded with a grant. When the grant ended, the CHWs were not able to be supported. This episodic funding has led to a fragmented use of CHWs.
As the articles in this issue demonstrate, CHWs play an important role in the overall health care team. If the goals of health care reform include cost-effective, accessible, and appropriate care to help people learn ways to stay as healthy as possible or to live more effectively with chronic illness, then the use of CHWs will be essential. As the issue editors summarize in the Foreword, the articles in this issue provide a range of descriptions of specific ways in which CHWs have served the people in the communities represented. I hope that each reader will take advantage of any opportunity both to explain the role that CHWs play in health care and to advocate for their inclusion in health care teams. It is important that a standard from of training be developed so that CHWs can become certified. This step would provide some measure of consistency in what a CHW knows and can do. The use of these workers also needs to be built into the budgets for health care organizations, and they should be paid at a rate comparable with other workers with similar skill. I hope that you find the articles valuable and also that you will become an advocate for CHWs whenever you have an opportunity to do so.
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