Do community health worker interventions embedded in primary care improve chronic disease health outcomes in medically underserved patient populations?

Abstract Background South Africa is an upper middle-income country, but has one of the widest GINI co-efficients in the world. It faces a heavy burden of disease and poor health outcomes remain a challenge for millions of South Africans. Slow economic growth, rapid urbanization and high unemployment could de-rail the efforts to improve access to health care and health outcomes amongst the most vulnerable in the country. Within this context, the introduction of large scale, comprehensive community health worker (CHW) programs, in urban areas are seen to be game changers. However, there is inadequate global evidence on whether such programs work. Methods This is a multi-method, quasi-experimental intervention study measuring the effectiveness of a CHW program in the Ekurhuleni health district; set in an urban province of South Africa, where CHWs support approximately one million people. Health indicator performance was compared in clinics with good coverage of CHWs and those with low or no CHW support. Poor and vulnerable households with CHW support were compared to those with no CHW support. Results Over a nine-year period since implementation, clinics with CHW programs improved better than clinics without; on identified pregnancy, child health, infectious disease and non-communicable disease indicators. Odds ratios showed that households with good CHW coverage had better social support, health-seeking behavior, morbidity and mortality than households without. p-values were statistically significant (<0.05) for social support, chronic disease diagnosis and chronic disease control outputs. Conclusions This CHW program has shown its worth as it has been effective in improving early screening, referrals, diagnosis and disease control across a number of health conditions in an urban setting. Key messages Large-scale comprehensive CHW programs are a good investment towards achieving universal health coverage for all by improving access and care to the poor and vulnerable. Community Health Worker services in households are effective and should be a legitimate level of health care delivery in developing countries.

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Community Health Worker Impact on Chronic Disease Outcomes Within Primary Care Examined Using Electronic Health Records

American Journal of Public Health ◽

10.2105/ajph.2017.303934 ◽

2017 ◽

Vol 107 (10) ◽

pp. 1668-1674 ◽

Cited By ~ 9

Author(s):

Maia Ingram ◽

Kevin Doubleday ◽

Melanie L. Bell ◽

Abby Lohr ◽

Lucy Murrieta ◽

...

Keyword(s):

Primary Care ◽

Chronic Disease ◽

Electronic Health Records ◽

Community Health ◽

Health Worker ◽

Community Health Worker ◽

Health Records ◽

Disease Outcomes ◽

Electronic Health

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Integrating a nationally scaled workforce of community health workers in primary care: a modelling study

Journal of the Royal Society of Medicine ◽

10.1177/0141076818803443 ◽

2018 ◽

Vol 111 (12) ◽

pp. 453-461 ◽

Cited By ~ 5

Author(s):

Benedict Hayhoe ◽

Thomas E Cowling ◽

Virimchi Pillutla ◽

Priya Garg ◽

Azeem Majeed ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Community Health ◽

Health Worker ◽

Community Health Workers ◽

Community Health Worker ◽

Health Workers ◽

Pilot Studies ◽

Cancer Screenings ◽

Home Based

Objective To model cost and benefit of a national community health worker workforce. Design Modelling exercise based on all general practices in England. Setting United Kingdom National Health Service Primary Care. Participants Not applicable. Data sources Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. Main outcome measures We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. Results Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. Conclusion A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

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Introduction of a community health worker diabetes coach improved glycemic control in an urban primary care clinic

Preventive Medicine Reports ◽

10.1016/j.pmedr.2020.101267 ◽

2021 ◽

Vol 21 ◽

pp. 101267

Author(s):

Chad M. Coleman ◽

Andrew S. Bossick ◽

Yueren Zhou ◽

Linda Hopkins-Johnson ◽

Mira G. Otto ◽

...

Keyword(s):

Primary Care ◽

Glycemic Control ◽

Community Health ◽

Health Worker ◽

Community Health Worker ◽

Primary Care Clinic ◽

Care Clinic

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Community health worker-delivered counselling for common mental disorders among chronic disease patients in South Africa: a feasibility study

BMJ Open ◽

10.1136/bmjopen-2018-024277 ◽

2019 ◽

Vol 9 (1) ◽

pp. e024277 ◽

Cited By ~ 14

Author(s):

Bronwyn Myers ◽

Petal Petersen-Williams ◽

Claire van der Westhuizen ◽

Crick Lund ◽

Carl Lombard ◽

...

Keyword(s):

Mental Health ◽

South Africa ◽

Chronic Disease ◽

Community Health ◽

Health Worker ◽

Community Health Worker ◽

Qualitative Interviews ◽

Chronic Disease Patients ◽

Hazardous Alcohol ◽

Health Counselling

ObjectivesTo examine the feasibility and acceptability of integrating a ‘designated’ approach to community health worker (CHW)-delivered mental health counselling (where existing CHWs deliver counselling in addition to usual duties) and a ‘dedicated’ approach (where additional CHWs have the sole responsibility of delivering mental health counselling) into chronic disease care.DesignA feasibility test of a designated and dedicated approach to CHW-delivered counselling and qualitative interviews of CHWs delivering the counselling.SettingFour primary healthcare clinics in the Western Cape, South Africa allocated to either a designated or dedicated approach and stratified by urban/rural status.ParticipantsForty chronic disease patients (20 with HIV, 20 with diabetes) reporting hazardous alcohol use or depression. Interviews with seven CHWs.InterventionThree sessions of structured mental health counselling.Main outcome measuresWe assessed feasibility by examining the proportion of patients who were willing to be screened, met inclusion criteria, provided consent, completed counselling and were retained in the study. Acceptability of these delivery approaches was assessed through qualitative interviews of CHWs.ResultsRegardless of approach, a fair proportion (67%) of eligible patients were willing to receive mental health counselling. Patients who screened positive for depression were more likely to be interested in counselling than those with hazardous alcohol only. Retention in counselling (85%) and the study (90%) was good and did not differ by approach. Both dedicated and designated CHWs viewed the counselling package as highly acceptable but requested additional training and support to facilitate implementation.ConclusionsDedicated and designated approaches to CHW-delivered mental health counselling were matched in terms of their feasibility and acceptability. A comparative efficacy trial of these approaches is justified, with some adjustments to the training and implementation protocols to provide further support to CHWs.

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Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa

Human Resources for Health ◽

10.1186/s12960-021-00696-8 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

L. S. Thomas ◽

E. Buch ◽

Y. Pillay ◽

J. Jordaan

Keyword(s):

South Africa ◽

Health Outcomes ◽

Community Health ◽

Health Worker ◽

Community Health Worker ◽

Large Scale ◽

Health District ◽

Health Seeking ◽

Middle Income ◽

Seeking Behavior

Abstract Introduction South Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings. Methods This study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district. Results The 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care. Conclusion A large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.

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