A Study to Assess the Effects of a Randomised Community Health Worker Intervention on Uptake of Preventative Care Services in London, UK

Background

Lay Community Health Workers (CHWs) are an inexpensive alternative to more costly health professionals, when delivering some interventions such as basic health promotion advice that does not require highly specialised health personnel.(1,2) Well conducted research shows that lay CHWs impact significantly on immunization schedule completion rates in the under-5s (RR 1.22, 1.10-1.37, p<0.001);(3) reduce overall morbidity in the under 5s (RR 0.86, 0.75-0.99, p<0.05);(3) treble exclusive breastfeeding rates at 6 months (RR 2.78, 1.74-4.44, p<0.001);(3) improve breast and cervical screening rates by 9.3% and 8.1% respectively (4,5) improve diabetes outcomes and blood pressure control.(5,6) Lay CHWs may be less qualified than clinicians or nurses, but because they are from the local community they are more understanding and empathetic of local issues and respond to community needs in a far more effective way than a healthcare professional would be able to do. Recent realist syntheses have shown that CHWs improve the access to public services, and increase self-esteem and a sense of self efficacy of the people they serve.(6) Recommended by the World Health Organisation (WHO) for all member States,(7) CHWs play an important role in the delivery of population-based primary care, particularly in response to COVID19 and vaccine hesitancy.(8) However, England has been slow to adopt a national, scaled CHW workforce as has been seen in other countries such as Pakistan, Ethiopia and Brazil.(9)

Since 1994, Brazil's scaled, national CHW model has led to significant improvements in population health outcomes. Rather than focussing on a priori need or sociodemographic characteristics, each CHW is responsible for 100-150 households in defined geographical areas and they visit each household on a monthly, or even more frequent, basis. This is a proactive, longitudinal approach, where CHWs build a trusting and continuous engagement with households. It has resulted in improved immunization and screening uptake because of personalised and tailored support, advice and signposting based on their intimate understanding of the household members, addressing concerns, cultural preferences, misinformation, and issues of access. This enables them to address all family members' needs and concerns much more effectively than when separate family members are targeted according to their socio-demographic and clinical characteristics, as occurs in the UK.(10) CHWs connect families to the wider health and social care ecosystem leading to reduced hospital utilization, admissions and inequalities, over time. Brazil is now deploying 270,000 CHWs to cover 100 million people across the country.(9,10)The CHWs have in part been responsible for a 4.5% reduction in infant mortality for each 10% increase in delivery of the CHW role;(11) a pro-poor increase in horizontal health equity; (12) a 13% reduction in hospitalizations for primary care sensitive conditions in municipalities with a high enrolment of the CHWs, even accounting for secular changes and other confounding variables,(13) and a 34% reduction in cardiovascular disease mortality in areas with high coverage of the CHW model.(14) In Brazil, this system has cost only $60 per person per annum.(15)

Context

Westminster is one of the worst performing local authorities for vaccine uptake (78% measles, mumps, rubella (MMR) MMR1, 85% diphtheria, tetanus, and pertussis (DPT), 60% COVID1, 53% COVID2, 21% COVID Booster, 38% Reception age flu vaccine, 61% 65+ flu vaccine),(16) due to its transient population (61% social renting),(8) but also because of the high proportion of Black, Asian, and Minority Ethnic (BAME) residents (49%) [16] and recent migrants (28% households have no English speakers).(17) In July 2021, Westminster Council piloted a new Community Health and Wellbeing Worker (CHWW) role in the Churchill Gardens Council Estate that was inspired by the Brazilian approach to primary care where CHWWs are responsible for defined micro-areas of around 120 households each, and have a mandate to visit each one, once per month, to provide health information, signpost to services, identify unmet need and promote health and wellbeing. In an evaluation of the Churchill Gardens pilot, which involved just four CHWWs visiting 120 households each in the first year of operations, there was an increased likelihood of uptake of immunizations (47%), screening (82%) and health check (190%) in visited households compared to unvisited households, for residents eligible for those services. This was due to proactive (through monthly home visits) identification of residents eligible for these services, resolving pressing social care concerns and having meaningful conversations around health and wellbeing.(18) Based on this experience, Westminster City Council (WCC), Healthcare Central London (HCL) (the four Primary Care Networks in Westminster) and One Westminster (the Voluntary sector) have collaborated to expand the CHWW pilot into the Lower Super Output Areas (LSOAs) in the bottom 20% deprivation centiles in North and South Westminster. Drawing on Additional Roles Reimbursement Scheme funds through NHS England, a further twenty CHWWs will be recruited in between September and December 2023. The overall aim of this research is to evaluate whether the scaled CHWW intervention leads to improved uptake of preventative care services (immunizations for all ages, cancer screening (breast, cervical and bowel) and NHS Health Checks) for households in high need areas (top 20% deprivation index) in London.