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

Lead Research Organisation: King's College London
Department Name: Health Service and Population Research

Abstract

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.

Technical Summary

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.

Planned Impact

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.
 
Description Member of advisory public policy. Fatima Alice Quadros was invited to be a member of a indigenous advisory group for the State of Mato Grosso do Sul
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Membership of a guideline committee
 
Description 005-2018-PIBEX-PROEC-UEMS. University Funding for undergraduate student
Amount R$ 400 (BRL)
Funding ID 005-2018-PIBEX-PROEC-UEMS. Samira Dias dos Passos supervised by Paulo de Tarso Coelho Jardim. 
Organisation Mato Grosso do Sul State University 
Start 07/2018 
End 07/2019
 
Description KCL Together
Amount £50,000 (GBP)
Organisation King's College London 
Sector Academic/University
Country United Kingdom
Start 04/2017 
End 03/2018
 
Description Newton Fund
Amount £136,604 (GBP)
Funding ID MR/R022739/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 04/2018 
End 10/2019
 
Description Rapid Response Research Grants
Amount £144,000 (GBP)
Funding ID MR/R022739/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 03/2018 
End 02/2019
 
Title Training of local researchers in concept mapping 
Description 4 x 3 hour sessions with 25 researchers and medical students at University of Mato Grosso du sul brazil 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? No  
Impact Researchers used the method in the study with indigenous communities 
 
Title Training of researchers 
Description 4 day course on qualitative methods covering theory, methods, process evaluation and role play 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact not yet assessed 
 
Description CVD in the Caribbean 
Organisation Jamaica Ministry of Health
Country Jamaica 
Sector Public 
PI Contribution Analysis of data Co-authorship of papers and conference presentations
Collaborator Contribution Collection and analysis of data Co-authorship of papers and conference presentations
Impact 2 papers published/submitted and 2 poster presentations Multi-disciplinary collaboration: social and clinical epidemiology, cardiovascular medicine, child health
Start Year 2009
 
Description CVD in the Caribbean 
Organisation King's College London
Country United Kingdom 
Sector Academic/University 
PI Contribution Analysis of data Co-authorship of papers and conference presentations
Collaborator Contribution Collection and analysis of data Co-authorship of papers and conference presentations
Impact 2 papers published/submitted and 2 poster presentations Multi-disciplinary collaboration: social and clinical epidemiology, cardiovascular medicine, child health
Start Year 2009
 
Description CVD in the Caribbean 
Organisation University of West Indies
Country Jamaica 
Sector Academic/University 
PI Contribution Analysis of data Co-authorship of papers and conference presentations
Collaborator Contribution Collection and analysis of data Co-authorship of papers and conference presentations
Impact 2 papers published/submitted and 2 poster presentations Multi-disciplinary collaboration: social and clinical epidemiology, cardiovascular medicine, child health
Start Year 2009
 
Description Control of hypertension in Jamaica 
Organisation King's College London
Department School of Medicine KCL
Country United Kingdom 
Sector Academic/University 
PI Contribution Lead on proposal for a community based intervention. Oultine proposal accepted.
Collaborator Contribution Developed grant proposal together - provide local expertise in epidemiology of hypertension in the Caribbean, in policy and practice environments Contributed to development of the proposal
Impact Outline proposal accepted. Mutlidisciplinary collaboration between university researchers (epidemiologists, social scientists, health economists, nutritionists, statisticians}, government scientists, community based organisations
Start Year 2011
 
Description Control of hypertension in Jamaica 
Organisation University of West Indies
Department Tropical Medicine Research Institute
Country Saint Vincent and the Grenadines 
Sector Academic/University 
PI Contribution Lead on proposal for a community based intervention. Oultine proposal accepted.
Collaborator Contribution Developed grant proposal together - provide local expertise in epidemiology of hypertension in the Caribbean, in policy and practice environments Contributed to development of the proposal
Impact Outline proposal accepted. Mutlidisciplinary collaboration between university researchers (epidemiologists, social scientists, health economists, nutritionists, statisticians}, government scientists, community based organisations
Start Year 2011
 
Description International comparative studies 
Organisation Academic Medical Center
Country Netherlands 
Sector Academic/University 
PI Contribution Provison of UK data sets to MEHO; Lead or co-author on peer reviewed papers
Collaborator Contribution Expertise in ethnicity and health in Portugal; Co-authorExpertise in ethnicity and health in Australia; Co-authorExpertise in analysing large data sets; Co-authorExpertise in sexual health; Co-authorLead on the Migrant and Ethnic Health Observatory (MEHO) study
Impact -Presentations at academic meetings and publications 19525262 19349162 18779736 17690159 17353202 16464611 16280368 16464611 18215540 16126153 18460352 18752157 19068281 17367725 20522433 19349162 +3 submitted MEHO's project
 
Description International comparative studies 
Organisation Medical Research Council (MRC)
Department MRC Social & Public Health Sciences Unit
Country United Kingdom 
Sector Public 
PI Contribution Provison of UK data sets to MEHO; Lead or co-author on peer reviewed papers
Collaborator Contribution Expertise in ethnicity and health in Portugal; Co-authorExpertise in ethnicity and health in Australia; Co-authorExpertise in analysing large data sets; Co-authorExpertise in sexual health; Co-authorLead on the Migrant and Ethnic Health Observatory (MEHO) study
Impact -Presentations at academic meetings and publications 19525262 19349162 18779736 17690159 17353202 16464611 16280368 16464611 18215540 16126153 18460352 18752157 19068281 17367725 20522433 19349162 +3 submitted MEHO's project
 
Description International comparative studies 
Organisation Queen's University Belfast
Country United Kingdom 
Sector Academic/University 
PI Contribution Provison of UK data sets to MEHO; Lead or co-author on peer reviewed papers
Collaborator Contribution Expertise in ethnicity and health in Portugal; Co-authorExpertise in ethnicity and health in Australia; Co-authorExpertise in analysing large data sets; Co-authorExpertise in sexual health; Co-authorLead on the Migrant and Ethnic Health Observatory (MEHO) study
Impact -Presentations at academic meetings and publications 19525262 19349162 18779736 17690159 17353202 16464611 16280368 16464611 18215540 16126153 18460352 18752157 19068281 17367725 20522433 19349162 +3 submitted MEHO's project
 
Description International comparative studies 
Organisation University of Coimbra
Country Portugal 
Sector Academic/University 
PI Contribution Provison of UK data sets to MEHO; Lead or co-author on peer reviewed papers
Collaborator Contribution Expertise in ethnicity and health in Portugal; Co-authorExpertise in ethnicity and health in Australia; Co-authorExpertise in analysing large data sets; Co-authorExpertise in sexual health; Co-authorLead on the Migrant and Ethnic Health Observatory (MEHO) study
Impact -Presentations at academic meetings and publications 19525262 19349162 18779736 17690159 17353202 16464611 16280368 16464611 18215540 16126153 18460352 18752157 19068281 17367725 20522433 19349162 +3 submitted MEHO's project
 
Description International comparative studies 
Organisation University of Western Australia
Country Australia 
Sector Academic/University 
PI Contribution Provison of UK data sets to MEHO; Lead or co-author on peer reviewed papers
Collaborator Contribution Expertise in ethnicity and health in Portugal; Co-authorExpertise in ethnicity and health in Australia; Co-authorExpertise in analysing large data sets; Co-authorExpertise in sexual health; Co-authorLead on the Migrant and Ethnic Health Observatory (MEHO) study
Impact -Presentations at academic meetings and publications 19525262 19349162 18779736 17690159 17353202 16464611 16280368 16464611 18215540 16126153 18460352 18752157 19068281 17367725 20522433 19349162 +3 submitted MEHO's project
 
Description Religious segregation and health 
Organisation Queen's University Belfast
Department Department of Epidemiology and Public Health
Country United Kingdom 
Sector Academic/University 
PI Contribution Expertise in social epidemiology
Collaborator Contribution Overall management of study, analysis and writing up of findings
Impact Gaining knowledge on public health implication of religious segregation in North Ireland
Start Year 2009
 
Description Concept Mapping 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Study participants or study members
Results and Impact Meetings to perform the Concept mapping with indigenous leadership, school teachers and indigenous community health workers to assess what they think is important and feasible to promote better nutritional and mental health among indigenous local youth and how that could be done through indigenous comunnity health workers in school setting.
Year(s) Of Engagement Activity 2018
 
Description Meetings with Local Indigenous Health Secretariat 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The aim of these meetings was to engage local indigenous health authorities in the research, as it was essential to have Indigenous Health Community workers on board for that, authorizations and support were needed.
Year(s) Of Engagement Activity 2018
 
Description NCD Prevention 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Sensitization to planned intervnetion programme
Year(s) Of Engagement Activity 2017
 
Description Readiness Assessment from Polo Base 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Media (as a channel to the public)
Results and Impact The purpose of this intervention was to evaluate the potential of local health workers (nurses, indigenous health workers, oral surgeon, nutritionist, physician) to engage in a health program and support activities focused on the participation of indigenous health workers in school programs that intend to improve mental and nutritional health of young indigenous sutdents. The activity had a positive outcome as it improved relations between University researchers and local health team.
Year(s) Of Engagement Activity 2018
 
Description community workshops with indigenous people 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact 18 Kalinago residents in Dominica attended 4 workshops to discuss priorities for prevention of NCDs
Year(s) Of Engagement Activity 2017