The Impact of Community Health Workers on the 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.

Intervention

CHWWs are a holistic, comprehensive, community-based support role. They are recruited from the local community (or within walking distance to it), paid full- or close-to-full time, and provide support and advice across all areas of the life course, and for any age group. This includes, but is not limited to, breast feeding advice, immunization and screening promotion and advice, healthy lifestyles and promoting wellbeing, improving community cohesion and social isolation, providing housing and social care support, signposting to wider services, identifying unmet need in households, identifying the early signs of, and supporting the management of chronic disease and any mental health issue, and referring in to the primary care team, community trusts, voluntary services and the Council services when required.

Each CHWW is deployed to cover around 120 households in defined geographies in North and South Westminster. Lower Super Output Areas (LSOAs) in the bottom 20% deprivation have been identified as priority areas for the CHWWs to be deployed and, within these LSOAs, sixty 'villages' of 120 households each have been mapped. These 'villages' are all localities that have over 80% registration of residents to the three participating GP practices where the CHWWs will be integrated into as part of their primary care teams. The intention is for all villages to eventually receive the CHWWs as part of a wider policy to create a workforce that is more place-based, proactive and personalised however, given there are not enough CHWWs being recruited in this expansion phase to cover all the 'villages', and given the need for a fair and equitable allocation of the CHWWs in this stage of the expansion, the provider consortium (HCL, WCC and One Westminster) have elected to randomly allocate 'villages' to either receive the CHWW or not. Residents will therefore have an equal chance of receiving the services of a CHWW, providing a perfect opportunity for a robust, parallel cluster study to determine the impact of the CHWWs in the intervention areas compared to the control areas, using retrospective analysis of data such as primary care service utilization, preventative service uptake and secondary care use in control and intervention households.

The intervention will involve monthly (or more frequent) household visits by the CHWW that was assigned to the village, enriched by a digitally-enabled intervention App with reminders and interactive educational materials for participants. All households in the villages allocated to receive the intervention will be approached by the CHWW allocated to that village, irrespective of demographic characteristics and previous needs. CHWWs will aim to visit all households each month, building a longitudinal relationship with each household so that problems arising from one month to the next can be captured in good time.

6\. Methods 6.1 Study Hypothesis

The hypothesis to be tested is that a multifaceted, proactive, place-based, neighbourhood-level community health worker-led intervention will improve the uptake of preventative care services for households in areas of high deprivation.

6.2 Trial/Study Design

This is a retrospective, observational evaluation of the uptake of preventative services in households allocated to the CHWW intervention, compared to those that received usual care. Taking advantage of the random allocation of the CHWWs to twenty out of sixty 'villages' identified in the LSOAs in the bottom 20% deprivation index, the evaluation will compare the outcomes in the parallel intervention and control clusters, with a retrospective baseline observation period, involving between 120-150 households per village per fulltime CHWW.

6.3 Study Population and Setting

Although one of the wealthiest London boroughs, home to the Government in Whitehall and main tourist hotspots, Westminster is an inner-city London borough characterised by areas of high deprivation, with many council or social housing estates that have large migrant populations, populations with multiple socio-economic needs, transient populations, and people living with multiple unmet health and social care needs. The council estates of Pimlico and Lisson Grove are particularly challenging in terms of high need, and hard-to-reach population groups. Both these areas, in North and South Westminster, are priority geographies for Westminster Council and its partner organizations, to address unmet need and improve access to services. In the context of this study, the deployment of the expanded cadre of CHWWs fits well with the agenda to improve access to services, supporting residents closer in their homes, and identifying and addressing unmet need. Adhering, though, to the model of deployment for the CHWWs, the provider organizations (HCL, WCC and One Westminster) have identified ten LSOAs in the lowest 20% deprivation index in these wider geographies. Within these LSOAs, HCL has identified all residents registered to GP practices in Westminster and wider afield. It has mapped the residents to households, by matching full addresses from the primary care records, and then geo-located households into discrete 'villages' of approximately 120 households in each. There are approximately sixty 'villages' where over 80% of the residents are registered to the three partnering GP practices (Lisson Grove Medical Centre, Paddington Green Health Centre in North Westminster, and Victoria Medical Centre) in South Westminster. Each cluster will be allocated either to receive the intervention (the CHWW) or serve as control. Residents of any age that are registered to the participating GP practices serving North and South Westminster and that are living in households within the clusters are included.

6.4 Eligibility Criteria The study population includes all residents eligible to receive the CHWW intervention if they are registered to a GP practice and live in a postcode that is in an LSOA that is in the bottom, i.e., most deprived, 20% deprivation index in the Lisson Grove or Paddington Green wards of Westminster.

6.5 Identification of Target Cohort HCL will identify the target cohort based on their address, deprivation index, and the GP practice where they are registered.

6.6 Randomisation and Allocation Concealment

HCL will conduct a 'village' (cluster) level, 1:2, computer-bas

• Individual components of the primary household composite outcome [Срок оценки: 2024-2026]
• Unscheduled GP visits [Срок оценки: 2024-2026]
• Total emergency department visits [Срок оценки: 2024-2026]
• Total hospitalizations [Срок оценки: 2024-2026]
• 30 day re-admission rates [Срок оценки: 2024-2026]
• All-cause mortality [Срок оценки: 2024-2026]