Primary Care and Public Health Services Integration in Brazil’s Unified Health System

摘要

Objectives. We examined associations between transdisciplinary collaboration, evidence-based practice, and primary care and public health services integration in Brazil’s Family Health Strategy. We aimed to identify practices that facilitate service integration and evidence-based practice. Methods. We collected cross-sectional data from community health workers, nurses, and physicians (n?=?262). We used structural equation modeling to assess providers’ service integration and evidence-based practice engagement operationalized as latent factors. Predictors included endorsement of team meetings, access to and consultations with colleagues, familiarity with community, and previous research experience. Results. Providers’ familiarity with community and team meetings positively influenced evidence-based practice engagement and service integration. More experienced providers reported more integration and engagement. Physicians reported less integration than did community health workers. Black providers reported less evidence-based practice engagement than did Pardo (mixed races) providers. After accounting for all variables, evidence-based practice engagement and service integration were moderately correlated. Conclusions. Age and race of providers, transdisciplinary collaboration, and familiarity with the community are significant variables that should inform design and implementation of provider training. Promising practices that facilitate service integration in Brazil may be used in other countries. The integration of primary care and public health is a key strategy, recommended nationally and internationally, for assisting underserved populations; it encourages community-focused initiatives and transdisciplinary approaches to practice. Integration allows health providers (e.g., physicians, nurses, health workers) to use individual- and community-level interventions to influence, respectively, individual behavior and community health. 1–3 Brazil’s Sistema único de Saúde (Unified Health System) was created as a result of Brazil’s 1988 federal constitution and the 1990 Lei Organica da Saúde (Organic Health Law). This law aimed to establish a large, decentralized health system offering free, universal care from medical consultations to organ transplants, health campaigns, and sanitation. 4 This system struggles with access, quality, and service coordination (e.g., scheduling, monitoring) mainly because it is incorporated under a single legal structure that contradicts decentralization and affects the integration of services that different sectors of the Sistema único de Saúde , such as hospitals, provide. 5 To integrate primary care and public health, the Sistema único de Saúde employs the Estratégia Saúde da Família (ESF; Family Health Strategy), a transdisciplinary approach used by health providers. ESF reflects “the new public health” paradigm, positing that integration best addresses health and environmental issues affecting communities. 6–8 The World Health Organization recommends that diverse providers pursue community-level outcomes and medical cost reductions through service integration. 9 Established in 1994 as the Programa de Saúde da Família , today the ESF consolidates a model of assistance operationalized by professional teams, including nurses, physicians, and community health workers (CHWs), that serve about 4000 individuals per team. 10,11 In Brazil, service integration is accomplished by transdisciplinary collaboration—providers delivering primary care alongside public health interventions (e.g., disease prevention campaigns). 11–14 Providers strive to engage in evidence-based practice (EBP), which is characterized by providers assessing the impact of environmental issues (e.g., water supply) on health and by incorporating patient input and research findings into diagnosis and treatment. EBP is encouraged by training local providers in integration methods. 15,16 ESF has improved adult patients’ awareness of their diagnoses and prognoses and their adherence to children’s immunization schedules and has decreased infant mortality, hospitalizations, and medication costs. 10,11,17–19.