Community health workers improving access to healthcare for people living in vulnerable circumstances in Belgium

Abstract

Belgium is below the European average with regard to equal access to health care. The group of people experiencing difficulties in accessing the health system in Belgium is growing. The COVID-19 pandemic hit the most vulnerable hardest and exacerbated existing social inequalities in access to care. Innovative ways are needed to make healthcare more accessible to these underserved vulnerable populations.
 The COVID-19 pandemic highlighted the importance of community health workers (CHWs) worldwide. Inspired by these CHW-programs, the Belgian Federal Government launched a project introducing the first CHWs throughout the country to improve access to care for people living in vulnerable circumstances. This study explores the mechanismes through which CHWs improved access to care during the COVID-19 pandemic in Belgium.
 In collaboration with fifteen CHWs, a photovoice study was conducted encompassing four phases: (1) a photovoice training; (2) participatory observation; (3) individual in-depth interviews; and (4) a closing focus group discussion. In addition, thirteen people who receive support from a CHWs took part in an individual in-depth interview. Furthermore, nine CHW-coaches participated in two focus group discussions. The study was submitted to the Social and Human Sciences Ethics Advisory Committee of the University of Antwerp, where ethical approval was received (SHW_21_55).
 The qualitative results show that CHWs reach people who live at a crossroads of different vulnerabilities, which are interrelated and can reinforce each other. This diversity in the people reached by CHWs results in a wide variety and often a combination of different care needs. These needs link to COVID-19-related care, primary care, questions concerning health insurance and welfare-related questions. People who live in vulnerable circumstances encountered various barriers that can interrupt the continuum of access to care - as conceptualised in the theoretical framework of this qualitative study based on the work of Levesque and colleagues (2013). The study demonstrates that CHWs consider this variety of barriers encountered by these people when providing support. Central to their work is building trust and providing unbiased help in an outreach way. In this way, they support a person throughout their access-to-care continuum.
 Qualitative research shows that CHWs can thus play a valuable bridging role between the Belgian healthcare system and people living in socially vulnerable circumstances who have little or no access to healthcare. Not only during the COVID-19 pandemic, but also afterwards they have the potential to play an important role in the Belgian health system. Access to health care was, is and will remain a major challenge for Belgium in the future.