Predictors of Service Integration By Transdisciplinary Health Team's in Brazil's Unified Health System

Background: Integration of social services (e.g., civil registration, community mobilization) with public health and primary care has been recommended as a key strategy by practitioners, researchers and policy-makers to solve the multifactorial determinants of chronic diseases. Despite efforts to increase service integration in the past 50 years, there is limited evidence on effective approaches to integrating myriad services. Our study investigated the influence of individual- and organizational-level factors, and job characteristics on service integration using 262 providers from Brazil’s Family Health Strategy (ESF) team. Brazil’s Unified Health System (SUS) is acknowledged worldwide as a model for studying integration as ESF transdisciplinary teams, which comprise of community health workers (CHWs), nurses, and physicians, are mandated to integrate services.

Methods: Cross sectional data were collected from 168 CHWs, 62 nurses and 32 physicians in Mesquita and Santa Luzia. Service integration was measured by three services: HIV prevention, community mobilization, and civil registration. HIV prevention refers to biomedical interventions that prevent the spread of HIV by blocking infection (e.g., condoms), decreasing infectiousness (e.g., antiretroviral therapy), or reducing acquisition/infection risk (e.g., medical male circumcision). Community mobilization is the participation of citizens in activities, such as community walks, geared towards understanding their sociopolitical environment.  Civil registration is the documentation of deaths, births and household information. We used structural equation modeling (SEM) to examine associations between service integration and job characteristics, individual- and organizational-level factors. Individual factors were measured by providers’ confidence, knowledge and skills, familiarity with the community, perseverance, and efficacy of the ESF team. Job characteristics were measured by transdisciplinary collaboration, provider’s autonomy in making decisions, ability to use a set of diverse skills; and patient-input. Organizational factors were measured by working conditions and availability of resources.

Results: Majority of participants were CHWs (64%); 24% nurses; and 12% physicians. Of the sample, 82% were females (n =214). The highest proportion of participants identified as Multiracial (123; 46%); 82 (31%) as White; and 54 (21%) as Black. The mean age was 34 (SD = 10); ranging from 20 to 70. Practitioners with experience of 5 years or more reported more service integration. Physicians, compared to CHWs and nurses, reported less integration. Black providers reported more integration than Whites and Multiracial providers. After accounting for all variables, community mobilization, HIV prevention, and civil registration were moderately correlated. The following variables positively influenced service integration: greater knowledge and skills; familiarity with the community; transdisciplinary collaboration; autonomy to make decisions; greater discretion by the job to use a variety of skills; perseverance; and ability to incorporate patient-input. No organizational-level factors influenced service integration.

 Conclusions: Practices such as trans-disciplinary collaboration and perseverance can be considered as offsetting the negative impact of organizational-level factors. Therefore, to increase service integration health systems should mandate transdisciplinary collaboration and provider trainings worldwide should incorporate activities that enhance providers’ confidence, perseverance, and ability to make decisions on the spot use diverse skills.