Factors Associated with Delivery of Drug Prevention Services By Health Services Workers in Brazil's National Family Health Strategy

Background: Brazil’s Unified Health Care’s Family Health Strategy is one of the world’s largest and most successful, social welfare programs. Comprised of 35,000 teams (ESF teams) of professional (e.g., physicians, nurses) and lay (Community Health Workers (CHWs)) service providers delivering primary care to nearly all of Brazil’s 5,560 municipalities, ESF teams operate in low-income communities burdened by chronic diseases and health disparities (e.g., diabetes, HIV, malnutrition, poor sanitary conditions, and drug abuse).  ESF workers offer counseling, preventive care, and referrals for treatment to municipal clinics and hospitals.  Workers collaborate across disciplines and have been credited with reducing infant mortality, improving immunization uptake, and reducing HIV transmission rates. As drug abuse has risen, along with incarceration rates due to drug-related offenses, drug abuse prevention has become a priority in Brazil. This paper sheds light upon the contextual factors associated with ESF workers’ delivery of drug abuse prevention services to community residents.

 Methods: Guided by Community Based Participatory Research, CHWs participated in the development of study aims, measures, and design. We collected cross-sectional data from CHWs, nurses, and physicians (n = 262). We used a logistic regression to assess workers’ delivery of drug prevention services operationalized as a dichotomous item: “I provide drug prevention services”. Predictors included demographics: age, education level, and job title (physician, nurse, CHW). Composite variables, constructed using factor analysis and subsequent scale analysis, included: workers’ capacity to engage in evidence-based practice (EBP), resource barriers (e.g., lack of training) to providing services, collaboration with colleagues (peer support), and provider awareness of evidence-based practice. 

Results: ESF workers’ peer support and their understanding of evidence-based practices positively influenced their delivery of drug prevention services. Workers that reported both high capacity to engage in EBP and high resource barriers to providing services were less likely to deliver drug prevention. Younger workers were more likely to deliver services.  Education level was not significantly associated, however CHWs, with the lowest levels of education among the sample, were more likely to deliver drug prevention.

Conclusion: Professional role, age, collaboration with colleagues, workers’ capacity to engage in, and their knowledge, about EBP, as well as their access to training, and resources, are crucial targets for informing the development of comprehensive education for workers delivering services in low-income communities in Brazil and in similar resource settings worldwide. CHWs may be able to offer drug prevention services more readily than nurses and physicians, by developing rapport and trust with community residents. Since they are most likely to offer services, CHWs ought to receive peer support, training in EBP, and access to training about drug prevention to support their efforts. Leveraging Community Based Participatory approaches to enhance ESF workers’ capacity in Brazil may help to inform interventions for health care workers worldwide.