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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Am J Public Health. Author manuscript; available in PMC Dec 28, 2012.
Published in final edited form as:
PMCID: PMC3477957
NIHMSID: NIHMS426208

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

Abstract

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.13 Brazil’s Sistema Único de Saúde (Unified Health System) was created as a result of Brazil’s 1988 federal constitution and the 1990 Lei Orgânica 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.68 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).1114 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, 1719

INFLUENCES ON SERVICE INTEGRATION

The literature suggests that associations between providers’ personal factors and transdisciplinary collaboration have an impact on providers’ engagement in both EBP and integration. Previous studies suggest that provider gender and age are associated with attitudes toward EBP, for example, women and older providers are more willing to engage in EBP. But providers’ race/ethnicity does not appear to be associated with willingness. Previous studies show that knowledge about the possible role of research in practice is associated with positive attitudes toward EBP, for example among substance abuse treatment providers who often integrate medical and psychosocial services.2023

Transdisciplinary collaboration is characterized by providers working side-by-side, incorporating diverse knowledge and solutions to health problems that transcend individual disciplinary perspectives.24, 25 Transdisciplinary collaboration is a process that influences service integration and EBP as follows. CHWs identify potential health problems and help patients access ESF physicians who diagnose and design treatment plans with the assistance of nurses and CHWs. Diagnoses and treatments are grounded in personal and environmental issues and community needs and resources. Nurses make appointments, dispense medication, and train CHWs to introduce public health campaigns, teach patients positive health behaviors, and advocate patients’ rights.10, 11 EBP is readily implemented because different providers see patients at different points in the continuum of care.

Transdisciplinary collaboration enhances providers’ confidence and willingness to engage in EBP.26, 27 Adherence to EBP processes facilitates providers’ abilities to help patients develop health promotion and disease prevention behaviors.16, 26, 28, 29 ESF providers are often knowledgeable about community needs, resources, and cultures. Familiarity with the community influences providers’ capacities to integrate services—from doctor visits to medication adherence to public health campaigns. 30, 31 Moreover, providers with previous involvement in research (e.g., as participants, recruiters, or intervention facilitators) are more willing to engage in EBP.23, 28, 32,33

CONCEPTUAL FRAMEWORK FOR INTEGRATION MODEL

Figure 1 summarizes key pathways to service integration and EBP engagement. This diagram depicts associations between demographics, individual factors, transdisciplinary collaboration, and both integration and EBP engagement. This model focuses on 4 areas of primary care and public health identified by providers and grounded in local epidemiological data.34, 35 However, the model can be adapted to focus on priorities matching other local needs.

FIGURE 1
Integration model path diagram summarizing conceptual associations: Family Health Strategy, Mesquita and Santa Luzia, Brazil, 2008–2010.

EBP is the process by which providers use patient input to identify research-based practices. 36 Our model does not focus on individual EBPs; it stresses providers’ use of research findings to guide assessment and treatment. Transdisciplinary collaboration facilitates integration because it uses the expertise of diverse providers.37

Associations between transdisciplinary collaboration, EBP, and integration have crucial implications for provider training. However, a knowledge gap exists regarding these associations. Processes that facilitate EBP and transdisciplinary collaboration have not received proper attention.38 We employed a structural equation model to examine associations between provider-level factors and transdisciplinary collaboration and 2 outcomes, EBP and service integration.

We focused on the integration of existing health promotion and disease prevention initiatives in Brazil, 2 areas with potential for integration2 in other countries, with the objective of building a model of associations between providers’ personal and interpersonal factors and their engagement in EBP and integration.

METHODS

US- and Brazil-based researchers and ESF staff developed a partnership over time.39, 40 We conducted research grounded in participatory research principles41 to improve provider training and transdisciplinary collaboration. Our pilot work included in-depth interview data from 42 providers to better understand service integration in Brazil. We developed a multidimensional survey42 grounded in interviews to collect data from 262 providers.

We sampled 168 CHWs, 62 nurses, and 32 physicians in 2 municipalities: Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State. The Brazil team had an ongoing professional relationship with ESFs in both locations. We collected data in 10 clinics in Mesquita and 20 in Santa Luzia, which represent various catchment areas. In each clinic, we recruited at least 1 physician (range = 1–2), 1 nurse (range = 1–5), and 1 CHW (range = 1–23). The average length of employment was 40 months (SD = 31; range = 4–156). Participation was voluntary, and we offered providers refreshments. Nurses with administrative duties recruited participants. Approximately 85% of staff in all clinics participated.

We used a cross-sectional design. Eight master’s level Brazilian interviewers administered surveys using password-protected mobile computers. Data were downloaded into and managed in a password-protected database (Illume 4.6; DatStat; Seattle, WA).43 Interviews were in Portuguese and lasted 45 to 75 minutes. We gave participants information about their rights, risks and benefits, and confidentiality.

Measures

The survey included 118 questions: providers’ demographics; familiarity with community; perceived success toward service integration; and opinions about research, EBP, and transdisciplinary collaboration. Providers had uneven reading and comprehension capacities, which required us to pilot test the survey with CHWs, nurses, and physicians. CHWs had difficulty understanding questions tapping their opinions and attitudes toward scientific research, and physicians found the survey too long. We used their input to correct for comprehensiveness and acceptability. We translated survey questions to English and back-translated them to Portuguese using standard protocol.44

Outcomes

We assessed 2 primary outcomes: service integration and EBP engagement. We operationalized service integration by 4 items measuring (from 1 = strongly disagree to 5 = strongly agree) providers’ perceived ability to assist patients with a range of priority initiatives, “I was successful in helping patients with: (a) prevention of infectious diseases such as dengue fever; (b) family planning and women’s health; (c) prevention of sexually transmitted diseases such as AIDS; and (d) adherence to doctors’ visits and medical regimens.”

We operationalized EBP by asking 31 questions and coding them on a 5-point Likert scale. We modified some items from existing measures45 and developed new items on the basis of our pilot work. We developed 5 scales on the basis of principal components factor analysis with geomin rotation and assessment of Cronbach α. Tables 1 and and22 show items and estimated factor loadings.

TABLE 1
Factor Loadings and Items for 3-Factor Solution: Family Health Strategy, Mesquita and Santa Luzia, Brazil, 2008–2010
TABLE 2
Factor Loadings and Items for 2-Factor Solution: Family Health Strategy, Mesquita and Santa Luzia, Brazil, 2008–2010

Cronbach αs were 0.69 or higher with the exception of providers’ information integration, which was 0.60. The 5 scales (confidence to care for patients, ability to ask appropriate questions, information integration, value of patient input, and use of patient input) represent a cohesive and comprehensive set of domains measuring EBP. We found a single dominant eigenvalue for the correlation matrix among the 5 scales, indicating that they reflected a unidimensional construct operationalized as EBP engagement.

Demographics and job context

We measured participant age in years. Race included White, Black, and Pardo—a broad classification encompassing mixed races, mulattos, and indigenous people, such as caboclos.46 We categorized gender as male or female. Physicians had medical degrees; nurses completed at least high school and had nursing degrees; CHWs had at least completed junior high school. We did not separately include an education variable because of its overlap with staff categories.

A dichotomous variable, clinic location, identified the 2 municipalities where the study took place. We used intraclass correlations (across 30 clinics) to determine if outcome measures from providers in each clinic were highly clustered in each clinic. For both outcomes, measures of intraclass correlations were small (0.014–0.054), indicating negligible clustering. We thus included only the dichotomous clinic location in subsequent analysis.

Individual factors

Participants gauged agreement with survey statements using 5-point Likert scales (1 = strongly disagree to 5 = strongly agree). Familiarity with the community was a single item “I know the latest news in my catchment area affecting patients.” Participation in research (yes or no) tapped participation as participants and other roles, such as recruiters “Have you participated in previous research?”

Transdisciplinary collaboration

Participants gauged their agreement with survey statements using a 5-point Likert scale. Importance of team meetings was a 2-item composite (Cronbach α=0.71) “Weekly meetings are important for discussing patients’ problems” and “for training and treatment planning.” We measured access to colleagues and consulting colleagues (outside meetings) by single items “I have access to colleagues to determine how best to help patients” and “I consult colleagues regarding patients’ treatments,” respectively.

Data Analysis

We calculated descriptive statistics summarizing control variables. We compared mean scores for the 4 integration items across demographic variables using analysis of variance F-tests or the Pearson correlation (for association with age). We conducted multiple pairwise comparisons using a Tukey adjustment to control for type I error at 5%.

We fit a structural equation model following the form of Figure 1. We treated the 4 indicators of integration as ordered categorical measures and the 5 scales measuring EBP engagement as continuous. We treated all predictors as continuous, although we created dummy variables where necessary (e.g., race). We allowed the structural residuals in the 2 outcomes and all predictors to correlate. There was a minimal amount of missing data that we handled using multiple imputations directly implementable in the software used (Mplus 6.1; Muthen & Muthen; Los Angeles, CA). We performed maximum likelihood estimation, and we used percentage of variability explained in each of the outcome latent variables to assess predictive performance of the model. When fitting models with categorical outcomes, standard structural equation model fit statistics—including the χ2 test (and df ratio) and root mean square error of approximation—are only available using robust weighted least squares (in Mplus)46. Thus we additionally fit the model using weighted least squares to obtain the overall model fit statistics.

The structural equation model in Figure 1 assumes that the predictors affect the observed outcomes only through their effect on the shared latent variables. Specifically, this implies that each predictor relates to the 5 measures of EBP engagement in a similar (albeit proportional) way. To assess this, we fit an additional structural equation model, which did not include the latent factor for EBP but instead treated each of the 5 scales as separate (but correlated) outcomes.

RESULTS

Table 3 shows the majority of participants (168; 64%) were CHWs, 62 (24%) were nurses, and 32 (12%) were physicians. The majority (214; 82%) were women. The highest proportion of participants (123; 46%) identified themselves as Pardo, 82 (31%) as White, and 54 (21%) as Black. The mean age was 34 years (SD = 10; range 20–70).

TABLE 3
Demographics and Service Integration: Family Health Strategy, Mesquita and Santa Luzia, Brazil, 2008–2010

Table 3 depicts providers’ integration of 4 priority areas. Average scores greater than 3 indicate agreement with providers’ ability to integrate the particular service. Across the total sample, agreement with integration of medical regimens and appointments (mean = 4.23) and prevention of infectious diseases (mean = 4.24) were significantly higher (P < .001) than was integration of family planning and women’s health (mean = 4.04) and HIV/AIDS prevention (mean = 3.97). Looking in specific services across groups, there were few significant differences. CHWs and nurses tended to have higher mean integration than did physicians, but this was significant only for medical regimens and appointments (P = .005). Older age was significantly associated with stronger agreement of integration of HIV/AIDS prevention (P = .049).

Summary model fit indices for the structural equation model were χ2 = 253.6 with df = 110, yielding a χ2/df ratio of 2.3 and root mean square error of approximation = 0.071, both indicating adequate model fit. Table 4 shows that physicians have significantly lower service integration than do CHWs (B = 0.211; P = .002) and shows a significant increase of integration with increasing provider’s age (Β = 0.168; P < .01). Familiarity with the community had a significant positive effect on integration (Β = 0.249; P < .001). Among transdisciplinary collaboration variables, endorsement of team meetings (Β = 0.287; P < .001) was associated with increased service integration. In total, these variables explained 26% of the variance in service integration.

TABLE 4
Structural Equation Model Estimated Path Coefficients for Service Integration and EBP Engagement: Family Health Strategy, Mesquita and Santa Luzia, Brazil, 2008–2010

Table 4 shows positive effects on EBP engagement for provider’s age (Β = 0.130; P < .05), and Black race exhibits lower EBP engagement compared with Pardo (Β = −0.158; P < .01). The effect from familiarity with the community to EBP was significantly positive and had moderate effect size (Β = 0.359; P < .001). Among transdisciplinary collaboration variables, endorsement of team meetings (Β = 0.325; P < .001) and consulting colleagues outside team meetings (Β = 0.191; P < .01) had significant positive effects on EBP engagement. These variables together explained 44% of the variance in EBP engagement.

After accounting for all other variables, EBP engagement and service integration were still moderately correlated (correlation = 0.495 [0.076]; P ≤ .001). Because of the importance of this overall relationship, we conducted post hoc analyses to assess if there was any unique correlation between each of the variables measuring EBP engagement and the composite service integration. We found that the residual correlation from providers’ knowledge about engaging patients in diagnosis and treatment with service integration was significant (correlation = 0.347; P < .001). This indicates that providers’ knowledge was more correlated with service integration than could be explained by its association with EBP. Moreover, the unique correlation between providers’ use of patient input in treatment planning with service integration, above and beyond the correlation with EBP, was also significant. Contrastingly, the association was negative (Β = −0.217; P < .001). Confidence in helping patients, incorporation of research results in practice, or valuing patient input did not have unique correlations with integration.

DISCUSSION

In the United States, a widening gap, currently 15 to 20 years, exists between the production of research-based practices and their use by providers.36 Most likely such a gap exists globally. Provider training and professional collaborative experiences can facilitate EBP.16, 47 Therefore, knowledge about the pathways connecting transdisciplinary collaboration, EBP, and service integration has implications for training providers globally.

Our research makes unique contributions in this area. First, we used data from a large sample of providers in Brazil’s ESF, whose mandate is to integrate primary care and public health. The sizable number of CHWs highlights a workforce seldom studied as equal members of transdisciplinary teams. Our collaborative work generated a survey comprehensible to providers with diverse education and reading capacities. Second, most research asks providers about endorsement of an EBP. Our innovative model uses a set of factors to reflect EBP processes and another set to capture integration of a range of initiatives reflecting local needs. Third, we have shown that providers’ familiarity with the communities they serve influences both integration and EBP processes. This is a particularly important finding because these associations have not been previously shown.

Grounded in our findings, we identified training strategies and practices to promote integration during the professional training and education of providers responsible for integrating primary care and public health. As hypothesized, providers’ familiarity with the community and their endorsement of team meetings influenced integration. Team meetings, ongoing consultations, and familiarity also influenced EBP engagement. Distinct from the new public health paradigm, provider training continues to focus on discipline-specific knowledge bases.48 Our findings suggest that, in addition to discipline-specific knowledge, training should advance providers’ understanding of the community where they work by studying day-to-day occurrences that can enhance knowledge of local cultures and priorities. Training should support collaboration between diverse providers and encourage all providers to follow CHWs’ lead, incorporating local knowledge into practice.4952

Our findings suggest that consulting with peers outside scheduled meetings may enhance integration and EBP engagement. Professional interactions will likely improve attitudes of providers reluctant to engage in EBP or transdisciplinary collaboration.29, 53 As in previous research, experienced providers endorsed EBP more strongly.21 These providers may be trained to mentor less experienced ones.

Black providers less strongly endorsed EBP engagement. Racial variations exist globally. Our study was not designed to examine racially based differences, and those found should be interpreted with caution. Given wide racial variations in Brazil,54 further research is needed to investigate the impact of racial identity on provider engagement in EBP. Future research should explore associations between membership in different racial categories and the impact of such membership on providers’ access to education and training and EBP engagement. Physicians less strongly endorsed service integration. Therefore, provider training should offer opportunities for improving diverse providers to help each other facilitate both integration and EBP engagement.26, 27 Transdisciplinary collaboration may thus help improve management and quality of care.55

Two measures of EBP appear to have unique effects on integration. The composite EBP engagement included measures about valuing and using patient input. Training should thus help providers specifically to develop knowledge and skills to engage patients by discussing diagnoses and treatments.5658 Because these measures were grounded in in-depth interview data, we note with caution the negative association between integration and providers’ use of patient input. Future research should tease out differences between these measures and further assess their impact on integration.

We found no significant association between providers’ involvement in research and EBP engagement. In light of research showing this association in a national sample of providers in the United States,23 further inquiry is recommended. A body of research on the processes and outcomes that characterize Brazil’s ESF is expanding. It is expected that-more ESF providers will be involved in future research. Their evolving experiences may inspire providers to engage in EBP and should be explored in such research.

Limitations

It is important to acknowledge limitations of this research. It focused on self-reports and is thus subject to bias and measurement errors requiring interpretational caution. We did not specify the intricacies of individual transdisciplinary teams that can be influenced by clinic-level data. We have not accounted for the distinct interests of different ESF professionals whose salaries and working conditions, often described as inadequate, may reduce the number and quality of their services.5, 59 However, the integration of primary care and public health services is a uniform mandate across ESFs, and 30 teams were represented here, improving our confidence that findings reflect the realities of most ESFs.

A longitudinal design would have allowed a more comprehensive understanding of changes in EBP and transdisciplinary collaboration over time. We used a measure representing a full range of initiatives that providers integrated, but these were not corroborated by patients. However, having identified associations between integration and key variables, we are encouraged to use, in future research, patient-level data to test associations between integration and patient outcomes.

Conclusions

In recognition of ESF’s limitations, including lack of integration of its primary activities with complex medical procedures (e.g., hospitalization, medication distribution), we emphasize that this study fills a significant gap in the literature by determining the direction and magnitude of factors influencing integration of primary care and public health in Brazil’s ESF. These findings can help guide provider training on integration that involves EBP and transdisciplinary collaboration worldwide. We recommend further research to uncover differential costs and benefits of integration in different countries. We posit that the irreplaceable role of CHWs, maintained at relatively low cost, can improve patient access to EBP.60 Our integration model, which accounts for expertise of diverse professionals and their synchronized integration of primary care and public health, is a promising strategy for improving the scope, cost, and quality of health care.

Acknowledgments

R. M. Pinto was supported by the National Institute of Mental Health, Bethesda, MD (grant K01MH081787).

The authors thank the Columbia University School of Social Work and the Institute for Latin American Studies at Columbia University for supporting this research with pilot and dissemination funding, respectively.

We thank research participants who graciously provided the data for this research. We also thank the following: Estratégia Saúde da Família providers and administrators critical to the execution of this research Ivanete Hindriches da S. Torres, Roselí Monteiro Silva, Gilberto da Silva Dorneles, Paulo de Tarso Machado Assis, Maria do Carmo de Castro Tófani, and Nádia Cristina Dias Duarte; our partners at Universidade Católica Rio de Janeiro Sueli Bulhões da Silva and Luíza Helena Nunes Ermel; and individuals who provided reviews of earlier drafts and overall support—Denise Burnett, Liliane Windsor, and Nabila El-Bassel.

Footnotes

Contributors

R. M. Pinto conceptualized the research and wrote the article. M. Wall oversaw data analysis and wrote parts of the article. G. Yu managed and analyzed data. C. Penido assisted in the conceptualization of the article and data collection. C. Schmidt assisted in the conceptualization of the article and contributed editorial comments.

Human Participant Protection

The Columbia University institutional review board approved this research.

Contributor Information

Rogério M. Pinto, School of Social Work, Columbia University, New York, NY.

Melanie Wall, New York State Psychiatric Institute, New York.

Gary Yu, Doctoral candidate at the Mailman School of Public Health, Columbia University.

Cláudia Penido, Estratégia Saúde da Família/Saúde Mental, Carreira Comprida, Santa Luzia, Brazil.

Clecy Schmidt, Estratégia Saúde da Família, Varginha, Silva Jardim, Brazil.

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