The potential contribution of community health workers to improving health outcomes in UK primary care

Abstract

Following the Alma Ata declaration which launched the concept of primary health care (PHC) to a global audience in 1978, there was a period of intensive controversy when different interpretations of PHC vied for ascendancy. In particular, there was contestation between comprehensive and selective approaches, the former as envisaged at Alma Ata and the latter exemplified by the UNICEF GOBI strategy (growth monitoring, oral rehydration therapy for diarrhoea, promotion of breastfeeding and childhood immunizations) and its subsequent modifications. A key component of both approaches was the role of lay community health workers in delivering a range of preventive and simple curative interventions as well as empowering and engaging communities in health-related activities. Variable and sometimes disappointing experiences with lay community health worker programmes including poor quality of care, lack of sustainability and lack of integration into the formal health system contributed to the ascendance of disease-specific vertical programmes. However, more recently it has been recognized that the proliferation of vertical programmes is inefficient and unsustainable and there has been renewed interest in the concept of comprehensive PHC with a central role for community health workers.

With more appropriate supervision and training, community health workers have been adopted in many low- and middle-income countries to promote health and wellbeing and help struggling health systems achieve the Millennium Development Goals, particularly for child health.^1–3 Around 30,000 health extension workers are employed in primary care settings in Ethiopia,⁴ the Lady Health Worker programme has been scaled up in Pakistan and now employs over 100,000 trained community health workers,⁵ and in Brazil over 250,000 community health agents have been integrated into primary care teams as part of the national family health strategy.⁶

There is growing evidence to suggest that lay community health workers can impact on a variety of individual and population health outcomes^7–9 and when appropriately organized and managed they can be an effective mechanism to improve health, empower communities and reduce healthcare costs where expensive, fully trained healthcare workers are not available.² In the right circumstances lay community health workers can be close to the community, can relate well to patients’ needs, provide a critical link to primary healthcare services and tailor health promotion messages in culturally appropriate ways.²

There are a handful of well-conducted meta-analyses that indicate that lay community health workers can produce positive health outcomes in a number of disease areas that are of relevance to the UK – child and maternal health and tuberculosis (TB) control,⁷ chronic disease management and care,⁸ and cancer screening for breast, cervical and bowel cancers.⁹ For example, Lewin et al.'s (2010) meta-analysis of studies from high- and low-income countries has shown that in four included studies, lay community health workers increase immunization schedule completion rates in the under-5s (RR 1.22, 1.10–1.37, P < 0.001); in six studies they reduce overall morbidity in the under-5s (RR 0.86, 0.75–0.99, P < 0.05); and in 10 studies they almost treble exclusive breastfeeding rates at six months⁷ (RR 2.78, 1.74–4.44, P < 0.001). Baron et al. (2008) found that across a total of 31 included studies, one-to-one education with lay health workers improved breast and cervical screening rates by 9.3% and 8.1%, respectively. Gogia and Sachdev (2010) have found that across five different research studies, home visits by lay community health workers significantly improved neonatal mortality rates (RR 0.62, 0.44–0.87, P < 0.0001). Finally, Lewin et al. (2010) found that across 10 included studies, lay community health workers improved TB cure rates by 22% (RR 1.22, 1.13–1.31, P < 0.0001).

One of the difficulties in assessing the impact of community health workers is the heterogeneity inherent in the interventions – this complicates the synthesis of research findings and systematic reviews.^7,10 It is generally quite a challenge to define what a community health worker actually is. Unlike the medical and nursing professions with their barriers to entry and regulatory structures, and where doctors and nurses can be accepted as conforming to some internationally recognizable standard, lay community health workers have no such framework. Lewin et al.⁷ define them as ‘any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree’. However, lay community health worker programmes often differ in the length of training; whether the community health worker is a paid worker or a volunteer; and whether the community health workers are employed by civil society, statutory or private sector organizations.² community health worker programmes also differ in their scope, intensity of intervention and site of delivery, and may employ a number of different techniques such as one-to-one counselling, directing patients to formal services, information provision, improving health literacy and group health education activities. This greatly complicates the comparison between interventions. For example, in Lewin et al.'s⁷ meta-analysis of studies that investigated the effect of community health workers on infant mortality, the included studies used interventions that ranged from simple education to referral and triage, through to basic clinical interventions; such as the use of de-worming tablets or even antimalarial medication. Equally, in these studies the community health worker delivered their interventions across a number of different sites, ranging from home visits, to community centres, or in rehabilitation programmes, and some even used folk singing to impart health promotion messages. Finally, the training requirements in each intervention were different, with some trained over just two days, and others over six weeks.

Such variation in intervention complicates the interpretation of research findings and the development of a robust evidence base for community health workers. This, together with the perception that the contribution of community health workers is predominantly in low-income countries, may partly explain why in the UK and other developed countries recruitment and integration of community health workers into primary care as an additional cadre has been sluggish at best. Developing countries and emerging economies have recognized their value, enough for community health workers to be the first point of entry into their more formal health system. However, in general terms, community health workers in developed countries are recruited only to provide additional support around behaviour change and peer-to-peer counselling for specific health domains. In the UK and other high-income countries, the development of a nationwide, community health workforce, integrated into primary care is yet to occur.

Lay community health worker models in the UK – what are the issues?

In the UK, there are already several types of lay community health workers, for example: health trainers, who focus on specific health promotion and behaviour change areas depending on the programme of work that they have been recruited to, e.g. smoking cessation, breast feeding support, sexual health, physical activity and so on. Visram and Drinkwater (2005)¹¹ identified over 40 different types of ‘health trainer’ in use in the UK which are variants on community health workers, with different levels of formal inclusion into the health system (Figure 1).
Figure 1
Examples of different types of ‘health trainers’ in the UK (Adapted from: Visram and Drinkwater, 2005)¹¹

Health trainers are well recognized as the principle lay community health worker in the UK. There are currently around 2200 health trainers,¹² generally considered to be part of the public health workforce, and recruited by primary care trusts (PCTs). Health trainers undergo some comprehensive low technical level training, usually a City and Guilds Level 3 equivalent, in a number of behaviour change and health promotion areas. These may include establishing and maintaining relationships with communities, how to communicate with individuals, how to support behaviour change and time management.¹³ There are further specific training programmes depending on the focus of their work, e.g. smoking cessation, breast-feeding, weight loss, physical activity and so on. Health trainers support individuals to develop their own personal health plans and although these individuals are frequently referred by general practitioners (GPs) they may also access health trainers via the PCT or on an ad hoc basis. Training is carried out locally, but is relatively well standardized across the UK. In addition to the service that they provide, training individual health trainers confers some employment stability and opportunity to advance a public health and/or community development or social care career. Health champions, on the other hand, do not have a health trainer qualification but they do work to support their activities by promoting the service at local health events, shopping centres, libraries and supermarkets.

The health trainer programme offers an important service for people seeking support around lifestyle changes; however, there is little or no robust evidence that the interventions are successful or cost-effective.¹¹ Descriptive evaluations often find that recipients are appreciative of the service, but this does not always translate into measurable differences in outcomes.¹⁴ Even in the research context it is difficult to associate the activities of a health trainer with reductions in hospital admissions and other important, measurable outcomes.

Perhaps related to this, outside of the research context, health trainers are not deployed in the systematic way that may be needed to fully exploit their potential. They operate in parallel to primary care services and although they may signpost and refer to GP practices, they generally do not work in or with GP practices directly. So although health trainers may have access to some detailed and nuanced health ‘intelligence’ gleaned by interacting with individuals, households and communities, this cannot be easily captured or used by GPs. Furthermore, they often work part-time, and there is a high turnover.¹² Lack of integration with existing primary care will inevitably lead to missed opportunities, but together with more established healthcare workers, such as the health visitors and specialist community nurses, there are over a dozen different types of community health workers, broadly defined, that have a mandate to interface with the household. This will inevitably lead to costly missed opportunities, inefficiencies and duplication.

In order to leverage the potential of a community health workforce it could be argued that this workforce needs to be accessible to the entire community and not just those that have been identified with a very specific health need, such as a desire to quit smoking. A much more systematic approach to a community health workforce is found in Brazil, where community health workers (there called community health agents) work as part of GP practice teams. Each community health worker covers around 100 households and each of these households are visited on a monthly basis, irrespective of need. At each visit, and in accordance with the health and social care context of the household, they promote healthy lifestyles, support breastfeeding, ensure vaccination schedules are complete, provide reminders for screening services, support the management of chronic diseases such as diabetes or hypertension through enhancing adherence, provide appointment reminders, develop and coordinate group education sessions – for example, around dietary advice – and finally because there is universal coverage, ensure that primary care population registers are kept up-to-date and in realtime. The systematic and comprehensive approach ensures that a new illness, or problems with adherence or a new pregnancy, is detected early on, in a proactive way. Weekly case discussion meetings are held in the GP practice to identify complex household issues and the community health worker receives ongoing training and support from the practice nurse. These are not separate projects or programmes designed and delivered locally, but nationally standardized, salaried, publicly funded, and fully integrated members of primary care teams used to impressive effect, such that the implementation of this primary care strategy, with lay community health workers at its core, has led to reduced hospitalizations for chronic disease and primary-care-sensitive conditions.^15–19

While this approach might not be immediately replicable in the UK, the underlying principles are relevant. Children, women, people with chronic disease, the elderly and those with mental illness are distinct groups with particular needs; however, they also have many common requirements – to be able to access basic health advice: to be directed to existing services; to be reminded when and how to take their medications, when to attend for screening and when immunizations are recommended; to be assisted to formulate questions about their health problems that can be addressed to health professionals, and to get help booking an appointment with the GP. It seems inefficient to have separate community health workers, each trained in specific areas, when these generic, basic activities are common to all. The targeted use of health trainers in the UK, as is currently conceived, may limit their potential – there would be value in fully integrating them into primary care and ensuring a more universal application across very small geographical areas.

It could be argued that investment in this cadre of health workers during a period of constrained NHS expenditure is inappropriate; however, there are likely to be several convincing arguments that will persuade policy-makers to invest in health trainers that are fully integrated into primary care. Firstly, it is increasingly difficult to recruit trained health professionals to carry out community-based interventions, e.g. health visiting and the health visitor workforce are actually shrinking. Recent policies to expand health visitor numbers look likely to fail, as even existing posts are frequently unfilled.^20,21 Secondly, expanding the lay community health worker workforce may provide employment and self-advancement for people who do not have the qualifications to work as health professionals, becoming a stepping stone to health professional training programmes for disadvantaged people. It is encouraging to know that, in addition to their impact on health outcomes, the Brazilian approach has also led to a 6.8% increase in labour supply and a 4.5% increase in school enrolment, suggesting that it is having broader societal impacts beyond the health system.¹⁸ Finally, a comprehensive, non-targeted, universal approach to community health workers might proactively identify new cases of early illness, chronic disease or mental health problems, before their consequences become costly to the individual and the health service. At the same time, this would reduce time spent in GP practices dealing with the relatively trivial issues that the community health worker could themselves resolve. In the long run it could be expected to be at least cost-neutral, if not cost-saving as has been the case in Brazil.¹⁸ It is worth bearing in mind that a universally applied community health workers workforce would be able to keep GP practice registers up-to-date and resolve the troublesome problem of list inflation that is both costly to the health economy and confounds local epidemiological profiling. While community health workers may have benefits in communities at all levels of socioeconomic development, it is probable that the greatest benefits may be in the most disadvantaged communities and therefore it would be appropriate for the initial implementation and evaluation to be undertaken in such settings.

There are several important research issues to be considered. Firstly, monthly household visits by a community health worker could be conceived as an excessive intervention and such a system might be viewed by some as paternalistic – the feasibility and acceptability of this approach should be explored. Secondly, intensive community health worker programmes could potentially reduce the direct and indirect costs of healthcare through more appropriate primary care consultations, and by providing care at a level closer to people's homes – so community health worker intervention studies should build economic evaluations into the design.²² Thirdly, community health workers are first and foremost community members and so issues of confidentiality may surface – research around medicolegal issues, etc. is required – and they should be bound by the same rules and regulations as, for example, medical receptionists.^7,12 Fourthly, the optimum ratio of community health workers to households may vary according to the socioeconomic and demographic characteristics of the community – the greater human resources already available in the NHS and level of health literacy in the community might mean that community health workers may be able to cover a larger number of households on average. Finally, information collected during home visits could be uploaded in realtime to GP practice databases – so the value of hand-held tablet technology should be explored. Clearly, lay community health workers must demonstrate cost-effectiveness before being scaled up.

Conclusion

Systematic reviews demonstrate that lay community health workers can improve a range of health outcomes in both high- and low- income countries when adequately trained and supported. Current investment in lay community health workers in the UK is piecemeal and has generally failed to integrate them into primary care services. We believe there is a plausible case to evaluate the use of lay community health workers integrated into primary care and employing a comprehensive approach in the UK. If these evaluations demonstrate the benefits we postulate, then there would be a good case for scaling up this approach.

DECLARATIONS

Competing interests

All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organization for the submitted work. MH spent four years working as a GP with Community Health Workers in the Brazilian Family Health Strategy

Funding

None

Ethical approval

None Required

Guarantor

MH.

Contributorship

MH is an Academic Clinical Lecturer in Public Health at Imperial College London. AH is Professor of Public Health and Primary Care at the London School of Hygiene and Tropical Medicine. MH and AH contributed equally to the writing of the manuscript and drew on systematic reviews, meta-analyses and randomized controlled trials to inform their considerations

Acknowledgement

We thank Margaret Cupples for comments on an earlier draft

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