Community health workers as partners in the management of non-communicable diseases
Authors: Héctor G Balcázar, Hendrik D de Heer
Journal: The Lancet Global Health (2015)

Community health workers are a vibrant and unique workforce ideally positioned to function as members of interdisciplinary teams needed to address the global burden of non-communicable diseases. The article by Thomas Gaziano and colleagues in The Lancet Global Health1Gaziano TA Abrahams-Gessel S Denman CA et al.An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment indicator in Bangladesh, Guatemala, Mexico and South Africa.Lancet Glob Health. 2015; (published online July 15.)http://dx.doi.org/10.1016/S2214-109X(15)00143-6Google Scholar provides a compelling scientific argument for incorporating community health workers into the systems of community-based screening and referral to predict cardiovascular disease risk as efficiently and accurately as physicians and nurses do. Gaziano and colleagues showed that, using a simple, non-invasive cardiovascular disease risk prediction indicator, 42 community health workers across four different countries completed 4049 screenings in a short timeframe with a high level of accuracy (96·8% agreement compared with the gold standard of a health professional). Low-income and middle-income countries carry an estimated 80% of the burden of non-communicable diseases2Alwan A Global status report on non-communicable diseases 2010. WHO.http://www.who.int/nmh/publications/ncd_report_full_en.pdfDate: 2011Google Scholar and are faced with a shortage of physicians3WHODensity of physicians total number per 1000 population.http://www.who.int/gho/health_workforce/physicians_density/en/Google Scholar and nurses to address population needs for screening, monitoring, and management. Gaziano and colleagues' study1Gaziano TA Abrahams-Gessel S Denman CA et al.An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment indicator in Bangladesh, Guatemala, Mexico and South Africa.Lancet Glob Health. 2015; (published online July 15.)http://dx.doi.org/10.1016/S2214-109X(15)00143-6Google Scholar provides an example of how community health workers can be part of a feasible and low-cost solution to these human and financial shortages. Through a brief structured training protocol (1–2 weeks, 61% of workers met the criteria to do fieldwork), the investigators showed that community health workers can help to detect early disease, which in turn can promote direction of resources to those in highest need and allow physicians and other health-care professionals to spend more time monitoring and treating disease. The article is a very timely contribution in the context of global challenges with the ailing medical model of disease care, and supports a shift towards population-based investments for prevention of non-communicable diseases that are absent at present.4Neupane D Kallestrup P McLachlan CS Perry H Community health workers for non-communicable diseases.Lancet Glob Health. 2014; 2: e567Summary Full Text Full Text PDF Scopus (31) Google Scholar A closer look at the results of Gaziano and colleagues' study1Gaziano TA Abrahams-Gessel S Denman CA et al.An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment indicator in Bangladesh, Guatemala, Mexico and South Africa.Lancet Glob Health. 2015; (published online July 15.)http://dx.doi.org/10.1016/S2214-109X(15)00143-6Google Scholar reveals several key findings. First, mobilisation of community health workers allowed for an effective way to reach community participants who did not have a previous diagnosis of cardiovascular disease risk factors such as hypertension and diabetes. Community health workers can draw on their in-depth knowledge of the communities' cultural norms, barriers, and opportunities—a strength that differentiates community health workers from other health-care professionals.5Balcazar H Rosenthal EL Brownstein JN Rush CH Matos S Hernandez L Community health workers can be a public health force for change in the United States: three actions for a new paradigm.Am J Public Health. 2011; 101: 2199-2203Crossref PubMed Scopus (155) Google Scholar Second, community health workers were able to integrate two key functions: screening and referral (non-urgent and urgent). Thus, community health workers showed they were able to assist a continuum of health care (screening and referral), which prevents community members from falling through the cracks in a system that because of human, financial, and organisational constraints is incapable of responding effectively and on time. Finally, Gaziano and colleagues report that community health workers did opportunistic screening for at least 100 community members over 4–6 weeks. Screenings were done in community sites or at the homes of community participants. Thus, community outreach has great potential to bridge prevention, management, and control of non-communicable diseases with empowering community models that incorporate community health workers as a part of the systems of health care and other systems within countries (schools, recreation facilities, churches, neighbourhood dwellings, etc). To communities, this integration would mean that an asset model of prevention within a health-care system can be developed. Moving forward, we identify several urgent needs and challenges. First, the standing of community health workers in the health-care systems needs to be legitimised and moved away from largely grant-funded temporary employees or volunteers who might provide educational services towards skilled members of the health-care system who can provide preventive and treatment services. As shown by Balcazar and colleagues,5Balcazar H Rosenthal EL Brownstein JN Rush CH Matos S Hernandez L Community health workers can be a public health force for change in the United States: three actions for a new paradigm.Am J Public Health. 2011; 101: 2199-2203Crossref PubMed Scopus (155) Google Scholar occupational regulation, job training and career development, and guidelines for common measures used in assessment and research can all contribute to more sustainable financing for community health workers. A step in this direction occurred in the USA in 2010 when community health workers were recognised by the US Department of Labor and assigned their own standard occupational classification (number 21-1094). Second, additional clinical models and studies need to show the feasibility and effectiveness of community health workers' work beyond educational services. The accurate cardiovascular disease screening and referral in Gaziano and colleagues' study1Gaziano TA Abrahams-Gessel S Denman CA et al.An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment indicator in Bangladesh, Guatemala, Mexico and South Africa.Lancet Glob Health. 2015; (published online July 15.)http://dx.doi.org/10.1016/S2214-109X(15)00143-6Google Scholar is an example of the type of service that workers can provide accurately and efficiently when trained appropriately. Several other studies have been published6Balcazar H Alvarado M Hollen ML et al.Salud Para Su Corazon-NCLR: a comprehensive Promotora outreach program to promote heart-healthy behaviors among hispanics.Health Promot Pract. 2006; 7: 68-77Crossref PubMed Scopus (73) Google Scholar, 7Balcázar HG Wise S Rosenthal EL et al.An ecological model using promotores de salud to prevent cardiovascular disease on the US-Mexico border: the HEART Project.Prev Chron Dis. 2012; 9: E35PubMed Google Scholar, 8Brownstein JN Chowdhury FM Norris SL et al.Effectiveness of Community Health Workers in the care of people with hypertension.Am J Prev Med. 2007; 32: 435-447Summary Full Text Full Text PDF PubMed Scopus (194) Google Scholar, 9Gaziano TA Bertram M Tollman SM Hofman KJ Hypertension education and adherence in South Africa: a cost-effectiveness analysis of community health workers.BMC Public Health. 2014; 14: 240Crossref PubMed Scopus (37) Google Scholar that show the ability of community health workers to be part of a team focused on screening and management of non-communicable diseases, and the time is right for expansion of this work. Third, this research will be increasingly effective for policy if it includes a systematic assessment of the value of services provided by workers. In a resource-limited environment, an increased emphasis will be placed on low-cost services for the beneficial health outcomes achieved. This situation presents an opportunity for community health workers to show their value in the health-care system and will be an important step towards creating more sustainable funding streams. Finally, research that can show the system-level requirements of taking the community health worker model to scale will be needed. For example, Singh and Sachs10Singh P Sachs JD 1 million community health workers in sub-Saharan Africa by 2015.Lancet. 2013; 382: 363-365Summary Full Text Full Text PDF PubMed Scopus (169) Google Scholar reported that one community health worker per 650 population would result in an estimated cost of only US$6·56 per person per year in sub-Saharan Africa. This type of assessment and vision will play an important part in the scaling up of the community health worker model and to solidify the worker as a legitimate and valuable part of the health-care team aimed at prevention, referral, and management of non-communicable diseases. We declare no competing interests. An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational studyHealth workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training. Full-Text PDF Open Access