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

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 outcomes7–9 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.