The association of Community Health Workers visits on healthcare utilization in Brazil: An analysis of the National Health Survey 2013-2019 PNS

Abstract

Introduction Aims/Objectives Community Health Workers (CHWs) are cornerstones of primary healthcare systems worldwide, improving access, equity, and outcomes while reducing avoidable costs. In Brazil's Family Health Strategy, CHWs conduct regular home visits as a key intervention. However, whether these home visits actually increase healthcare service utilization remains unclear. The aim of this study is to examine the association between CHW home visit frequency over the previous 12 months and recent healthcare-seeking behavior, analyzing multiple access indicators. Methodology A cross-sectional analysis incorporated pooled datasets from 2013 and 2019 Brazilian National Health Survey data for residents 15 years of age and older. The exposure was CHW home visit frequency (any visit vs. never) in the previous 12 months. The outcomes examined were care-seeking (in the last two weeks), and healthcare utilization outcomes in the previous 12 months (doctor visits, hospitalizations, emergency visits, follow-up for chronic disease, preventive care whether from a physician or CHW, smoking cessation services, etc.). Prevalence ratios from survey-weighted Poisson regression with robust variance were estimated. All models were adjusted for sociodemographic and health-related factors. A complete-case analysis was conducted, with 95% confidence intervals. Results The majority of utilization indicators increased from 2013 to 2019 (e.g., any consultation 71.2% - 76.2%). After adjustment, any CHW home visit over the past 12 months was not associated with any two-week care-seeking (aPR 0.97, 95% CI 0.92–1.03) or secondary outcomes (emergency care, hospitalizations, chronic-disease follow-up, screening). Conclusion In this nationally representative Brazilian study, CHW home visits were not associated with healthcare utilization after controlling for sociodemographic and regional variables. Utilization was more strongly associated with the socioeconomic determinants than CHW visits would indicate in Brazil's universal system. Collectively, the evidence base suggests that CHWs have their impact mainly in health literacy and prevention, areas that are poorly captured by any utilization metric with a short recall period.