Disparities in health and wellness have been documented in the United States and are due to many factors, including unequal access to care health care (Minas et al., 2020), as well as nonmedical factors that influence health outcomes (Alcaraz et al., 2020; Coughlin, 2020, 2019; Krok-Schoen et al., 2015; Chattopadhyay, 2020). Barriers to preventive services and recommended care often include fear or distrust of the medical community, lack of or inadequate health insurance coverage, financial hardship, low levels of health literacy and education, and logistical issues, such as lack of transportation (Katz et al., 2014; Rohan et al., 2016). Community health workers (CHWs), with a long history of working in communities, are increasingly working to address these challenges within health care settings (Malcarney et al., 2017). The American Public Health Association defines a CHW as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery” (American Public Health Association, 2023). CHWs may have a variety of titles, including promotores de salud, community health representatives, community health advisors, and peer navigators, and have long been part of the US public health system (Brownstein et al., 2011; Community Health Worker Core Consensus Project, 2013; Kangovi et al., 2015) and community-based organizations (Martinez, 2008).

Research has demonstrated that CHWs are effective in increasing screening use for breast (Guide to Community Preventive Services, 2023a; Wells et al., 2011), colorectal (Guide to Community Preventive Services, 2023b), and cervical cancers (Guide to Community Preventive Services, 2023c; Okasako-Schmucker et al., 2023), helping manage chronic conditions, such as diabetes and cardiovascular disease, and helping manage risk factors, such as high blood pressure and cholesterol (Jacob et al., 2019; Vasan et al., 2020). CHWs also promote health equity by helping individuals address social determinants of health (SDoH), such as food insecurity, housing, transportation, and childcare, as well as advocating for policies that support health equity (Enos, 2019; Gunderson et al., 2018; Kangovi et al., 2015; Katz et al., 2014; Minkler et al., 2010; Chattopadhyay, 2020; Roland et al., 2017). The Centers for Disease Control and Prevention (CDC) has long recognized the contributions of CHWs in clinical and public health practice. Most recently, in 2021, funding for the Community Health Workers for COVID Response and Resilient Communities was provided by CDC to support hiring, training, and deployment of CHWs nationwide across 67 organizations with an investment of more than $340 million (Centers for Disease Control and Prevention. Community Health Workers for COVID Response and Resilient Communities [CCR], 2023).

Primary care practitioners (PCPs) may also play an important role in reducing health disparities (Coughlin et al., 2019) by providing care to those with chronic conditions, offering chronic disease management counseling, encouraging patients to receive recommended screenings, and referring patients to appropriate services and interventions. Incorporating CHWs into primary care teams can improve patient outcomes (Ferrer et al., 2022); however, barriers to effectively integrating CHWs into primary care teams and programs persist (Gore et al., 2020; Greenwood-Ericksen et al., 2021; Gupta et al., 2023; Sherman et al., 2017). For example, some health care providers have reported struggling to identify CHWs and meet existing needs in clinical settings, and funding CHW positions can be challenging (Greenwood-Ericksen et al., 2021; Sherman et al., 2017). Members of multidisciplinary care teams have reported a lack of information about CHW roles, scope of practice, and clear workflows (Gore et al., 2020; Greenwood-Ericksen et al., 2021).

There is little information about how PCPs, in general, interact with CHWs or perceive CHW roles. Using a nationally endorsed framework for CHW competencies and roles (Community Health Worker Core Consensus Project, 2013), we sought to better understand PCP awareness and understanding of and engagement with CHWs in adult primary care settings. Specifically, we sought to answer several research questions: (1) Are there differences in PCP involvement with CHWs based on PCP demographics, practice characteristics, and patient profiles? (2) Among PCPs who report involvement with CHWs, what is their knowledge of CHW roles, and what do they perceive as the benefits of and barriers to working with CHWs? and (3) Among PCPs who have not worked with CHWs, what could facilitate engagement with CHWs? Gaining additional insight into provider knowledge gaps can help public health practitioners facilitate better integration of CHWs into primary care settings to reduce health disparities.

We used data from the fall 2022 DocStyles survey, a web-based survey of PCPs (internists, family practitioners, obstetricians/gynecologists [OB/GYNs], pediatricians, nurse practitioners, and physician assistants) commissioned by Porter Novelli Public Services and fielded from September 9 to November 3, 2022 (Porter Novelli Public Services, 2023). Five questions about working with CHWs were included in the survey, which contained 109 survey questions in total. Since the CHW-related questions pertained to chronic illnesses primarily seen in adults, they were not asked of pediatricians. Respondents were paid an honorarium of $50-$65. The data did not include identifiable information, and this activity was reviewed by CDC and was conducted in accordance with applicable federal law and CDC policy.

Among 1504 survey respondents, 55% (n = 829) reported engagement with CHWs, either directly or indirectly, and 45% (n = 675) reported no involvement with CHWs (Table 1). Most survey respondents were under age 50 (63%), male (57%), and identified as non-Hispanic White (61%). Survey respondents were primarily internists (36%) or family practitioners (30%), who more often reported having been in practice for less than 20 years (64%). Most respondents worked in a group outpatient setting or clinic (65%) and practiced in a suburban setting (51%).

Respondents who reported higher levels of involvement with CHWs relative to the respective comparison groups were under age 40 (59%; P = .05), were nurse practitioners (65%; P = .05), and practiced in urban areas (60%; P = .03) (Table 1). Involvement with CHWs was highest for respondents working in urban American Indian/Alaska Native or tribal health clinic settings (100%), FQHCs (79%), and community health centers (71%) (P < .0001). Involvement with CHWs was also higher among respondents seeing 125 or more patients per week (62%; P < .01) and respondents who more frequently saw patients with household incomes below $25 000 - per year (68%; P = .05). Involvement with CHWs was less frequently reported among respondents practicing for 30 or more years (47%; P = .05) or who had an individual outpatient practice (48%; P = .05).

Our examination yielded several differences regarding PCP engagement with CHWs in adult primary care settings, including their perceptions of CHW roles, perceived benefits to patients receiving CHW services, and perceived barriers to engagement with CHWs. Among the 55% of PCPs who reported working with CHWs, involvement differed somewhat by PCP demographic and practice-related factors. The finding that younger and less experienced providers are more likely to work with CHWs could be because medical education and residency programs are newly beginning to emphasize the role of CHWs and SDoH in shaping health outcomes (Kangovi et al., 2018). Continuing medical education courses on the role of CHWs and the value of integrating them into health care practices may be helpful for the 45% of providers who do not interact with CHWs, particularly those who are more seasoned. Because providers working in rural areas are less likely to work with CHWs, there may be a need for workforce development to support CHWs in rural communities, particularly given evidence that CHWs improve access to care in rural settings (Berini et al., 2022). Our findings that PCPs affiliated with urban American Indian/Alaska Native or tribal health clinic settings, FQHCs and CHCs, nurse practitioners, PCPs seeing a high volume of patients per week, and PCPs seeing patients with lower household incomes reported higher involvement with CHWs were not unexpected, given that many FQHCs have a long history of robust CHW programming (Gore et al., 2020; Greenwood-Ericksen et al., 2021; Roland et al., 2017) and that CHWs generally work with under-resourced communities (Fingerhood, 2018; Viswanathan et al., 2010).

As with a previous study of PCPs in Arizona (Arizona Prevention Research Center, 2015), our findings demonstrate that providers perceive CHWs to be engaging in most nationally endorsed CHW roles (Community Health Worker Core Consensus Project, 2013). Provider understanding of what CHWs do is essential to successful integration of CHWs into the health and public health workforce, since prior studies have shown that limited knowledge of CHWs scope of practice within an organization presents a major challenge to CHW effectiveness (Sherman et al., 2017; Wennerstrom et al., 2015). Providers in this sample generally appear to understand CHW roles, particularly those that are tied to promoting health equity and addressing SDoH (eg, individual and community advocacy, providing culturally appropriate health education, and assessing individual and community needs), in addition to those that are more clearly connected to promoting health care access (eg, service coordination). This is promising, since there is evidence that CHWs working in well-integrated health care teams routinely address health disparities (James et al., 2019; Johnston et al., 2019; Mobula et al., 2015; Paulson et al., 2021) and empower patients to advocate for themselves more effectively with PCPs (Paulson et al., 2021). As well, participants’ perceptions of how CHWs benefit patients (eg, by increasing access to care, better managing chronic health conditions, following medical recommendations, having more effective communication with office visits, and being up-to-date on preventive screenings) are consistent with evidence that CHWs do, indeed, contribute to such outcomes (Berini et al., 2022; Guide to Community Preventive Services, 2023a, 2023b, 2023c; Jacob et al., 2019; Vasan et al., 2020). These findings also suggest that PCPs familiar with CHWs value their professional contributions.

Our finding that PCPs perceive that funding is a barrier to fully integrating CHWs into health care teams is consistent with other studies (Arizona Prevention Research Center, 2015; Wennerstrom et al., 2015). CHW positions are largely grant-funded, and, despite numerous (Guide to Community Preventive Services, 2023c) efforts to establish sustainable financing approaches for CHW services over the last decade, significant challenges remain. For example, Medicaid State Plan Amendments (SPAs) have been granted in several states to allow for payment of some CHW service. Reimbursement for CHW services may help to incentivize provider groups to recruit and retain CHWs. SPAs generally support a fee-for-service (FFS) reimbursement model, which may lack clarity in state CHW reimbursement policies and billing codes and processes (Gunter et al., 2023). Moreover, Medicaid FFS models are unlikely to support CHWs in enacting roles that are not directly related to patient care (eg, advocacy and social support), and they cannot serve uninsured populations (Centers for Disease Control and Prevention. Community Health Workers for COVID Response and Resilient Communities (CCR), 2023).

The findings of this study can inform ongoing efforts to advance health equity through the integration of CHWs into primary care practices. The need for PCPs to have a clear understanding of the roles, skills, and qualities of CHWs is especially important now, due to recent national-level policy developments that have the potential to change the landscape of how CHWs are engaged and funded in clinical health care. Specifically, the 2024 Physician Fee Schedule final rule (Centers for Medicare Medicaid Services, 2023) issued by the Centers for Medicare and Medicaid Services (CMS) includes the availability of separate Medicare payments for collection of SDoH information from patients, an activity that could be performed by CHWs. Additionally, the CMS rule created new codes to enable billing for community health integration services to address health-related social needs, another area where CHWs have expertise. CHWs, along with their allies such as public health practitioners who authentically engage CHWs (ie, include CHWs in decision-making and leadership roles), are uniquely positioned to educate health care providers and practices about the roles of CHWs. In particular, CHWs and allies could collaborate to develop continuing education modules on CHW roles and activities for practicing physicians, as well as curricula for medical schools and residency programs. They may also support integration of CHWs into primary care practices so that CHWs can contribute to providing patient-centered care, including recognizing and addressing social needs at the individual, family, and community levels. We hope this initial study provides a foundation for future studies to more fully understand the barriers to integrating CHWs into primary care settings, which could support the development of resources needed to more effectively integrate CHWs into primary care settings.