Strengthening the primary care system for adolescent indigenous health in Brazil: Integrating community health workers into the school setting

Indigenous people all over the globe experience worse health and living conditions that non-indigenous people. Historic social and political forces are key factors but weak health systems also contribute to the explanation. Adolescent health is important, and represents an opportune time for intervention. This is of critical importance for indigenous communities, as the transition to adulthood is much quicker with earlier parenting and caring responsibilities compared to non-indigenous communities. Health priorities for Brazil, outlined in the United Nations High-Level Political Forum of 2017, include non-communicable diseases and diseases resulting from external causes (especially violence) with a focus on Sustainable Development Goals 1, 2, 3, 5, 9 and 14, and on the central theme "Eradicating Poverty and Promoting Prosperity in a Changing World". Nowhere is this more pertinent than for their Indigenous populations whose children face the challenge of a legacy of social injustice and poor health.

There are ~1 million indigenous people in Brazil, of which ~50% is <24y. Mato Grosso do Sul, the location for the proposed study, contains the 2nd largest concentration of indigenous people (70,000), and 70% are <20y. A lot of thought and investment has gone into the indigenous health system in Brazil but health of indigenous people still lags behind non-indigenous people. Community health workers represent an opportunity for improving the indigenous health system, based on evidence of effectiveness in other country settings. We will co-design an intervention in schools using CHWs to deliver universal and targeted services for health promotion, screening for health problems and early intervention. We will work with the local indigenous adolescents, teachers, and health professionals to design the content of the intervention and evaluation. We will conduct surveys to examine what processes work best and how they works to strengthen the indigenous primary care systems. To assess the influence of CHWs, we will collect data on satisfaction and health literacy. We will also gather information on health outcomes, which together with the other findings from this study will help us plan future large scale studies of the effectiveness of CHWs in schools. This new and important research will help us explore how to help indigenous young people avoid the ill health that their parents' and generations before them have experienced.

There is global recognition of the social injustices and poor health that indigenous people endure. Health priorities for Brazil focus on several Sustainable Development Goals realted to non-communicable diseases and poverty. There are ~1 million indigenous people in Brazil, of which ~50% is <24y. Mato Grosso do Sul, the location for the proposed intervention, contains the 2nd largest concentration of indigenous people (70,000), 70% are <20y. Adolescence is a crucial period for developing health or disease risk trajectories. There is strong evidence for a pivotal role of community health workers (CHWs) in primary care but their effectiveness in secondary schools has not been evaluated. A feasibility study will explore whether CHWs can be trained to deliver universal and targeted services for health promotion, risk screening, and early intervention. We will work with local indigenous adolescents and parents, teachers and health professionals to ensure adaptability in delivery to best suit the needs of the pupils in different schools but all CHWs will have the same roles and responsibilities to promote adolescent health and use evidence-based materials. Based on the principles of realist evaluation and MRC guidelines for the evaluation of complex interventions, we will use a mixed methods approach including: 1) concept mapping with stakeholders to develop a model of factors that could affect implementation in the primary health care system and schools; 2) interviews with pupils, teachers, CHWs, and supervising nurses to understand the barriers and facilitators of implementation and 3) quantitative surveys to obtain useful data for needs assessments, and also examine likely influence of the intervention on adolescent health literacy and satisfaction with the intervention. If the findings are favourable, we will conduct wider testing of the intervention in collaboration with the indigenous communities and the health secretariat.

Who might benefit from this research and how?
This proposal seeks to integrate primary care and schools via CHWs to improve health system delivery as well and physical and mental health outcomes in indigenous adolescents. The research will provide improved integration of health services, increasing opportunity for health promotion and public health awareness through the school based curriculum, and delivered by CHWs.
Indigenous youth, families, teachers and healthcare professionals will benefit from this research. Adolescents will benefit from the research through investment in adolescent health and tailored care pathways (e.g. school kiosks) specific for their mental and physical health needs. Early identification of adolescents at risk of mental or physical problems, improved rates of referral to care and access to treatment are key benefits of the proposal. Families and teachers will benefit from the dissemination of health promotion activities and engagement with evidence based advice and support.
The health service will benefit significantly as a result of the proposed research. Improved service delivery tailored to local needs, improved health promotion and diffusion of health promotion messages to local communities, as well as increased rates of referral, and more importantly, appropriate referral are anticipated. Benefits to the health service may also include redistribution of health capital and services (eg doctors, nurses, dentists) who currently deliver health promotion in schools. Integration of the CHWs will allow these health professionals to focus on areas of need elsewhere. CHW may also increase acceptance of the intervention (CHWs are largely members of the indigenous communities they serve) resulting in improve rates of referral for care. These anticipated benefits will directly impact adolescent health and, likely health of future generations, particularly given the early entry of indigenous adolescents to parenthood. The benefits of the proposed research may also extend to the broader health subsystem. If successful the proposed intervention could be tested beyond the target regions of Sidrolândia and Dois Irmãos do Buriti in Mato Grosso do Sul. Schools will also have a beneficial impact of the current study as they will become a focal point for health promotion and improve health service integration. Training delivered to CHWs will include also teachers to assist in the early identification of health needs in adolescent pupils.
Researchers focused on indigenous health, particularly, will also benefit from comprehensive health profile data from a largely unreported, cohort of indigenous youth which can be used to inform future research among indigenous communities. Screening and research tools tailored to the specific needs of the indigenous population will also be derived during the proposed research and will also add value for researcher in indigenous research.
Lastly, the impact of the intervention may also have national significance in that it may assist in strengthening existing health policy to promote improved integration between primary care and schools and extend the role of CHWs. Adjunct policies which could be revised if the results are favourable include the National Policy on Health Care for Indigenous Peoples; National Policy on Continuing Education in Health; National Policy on Health Promotion; National Policy for Comprehensive Health Care for Adolescents and Youth; National Policy on Primary Care.
By leveraging the existing model of care and developing improved interface between schools and primary care there is the potential to significantly strengthen the existing subsystem and improve health outcomes in indigenous youth.