International Journal of Drug Policy 26 (2015) 509–515

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research paper

Implementation of Brazil’s “family health strategy”: Factors associated with community health workers’, nurses’, and physicians’ delivery of drug use services Anya Y. Spector a,∗ , Rogério M. Pinto b , Rahbel Rahman b , Aline da Fonseca b a HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 722 West 168th Street, Room 307, New York, NY 10032, United States b Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States

a r t i c l e

i n f o

Article history: Received 31 May 2014 Received in revised form 28 November 2014 Accepted 7 December 2014 Keywords: Brazil family health strategy Transdisciplinary collaboration Community drug use services

a b s t r a c t Background: Brazil’s “family health strategy” (ESF), provides primary care, mostly to individuals in impoverished communities through teams of physicians, nurses, and community health workers (CHWs). ESF workers are called upon to offer drug use services (e.g., referrals, counseling) as drug use represents an urgent public health crisis. New federal initiatives are being implemented to build capacity in this workforce to deliver drug use services, yet little is known about whether ESF workers are providing drug use services already. Guided by social cognitive theory, this study examines factors associated with ESF workers’ provision of drug use services. Methods: Cross-sectional surveys were collected from 262 ESF workers (168 CHWs, 62 nurses, and 32 physicians) in Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State. Outcome variable: provision of drug-use services. Predictors: capacity to engage in evidence-based practice (EBP), resource constraints, peer support, knowledge of EBP, and job title. Logistic regression was used to determine relative influence of each predictor upon the outcome. Results: Thirty-nine percent reported providing drug use services. Younger workers, CHWs, workers with knowledge about EBP and workers that report peer support were more likely to offer drug use services. Workers that reported resource constraints and more capacity to implement EBP were less likely to offer drug use services. Conclusion: ESF workers require education in locating, assessing and evaluating the latest research. Mentorship from physicians and peer support through team meetings may enhance workers’ delivery of drug use services, across professional disciplines. Educational initiatives aimed at ESF teams should consider these factors as potentially enhancing implementation of drug use services. Building ESF workers’ capacity to collaborate across disciplines and to gain access to tools for providing assessment and treatment of drug use issues may improve uptake of new initiatives. © 2014 Elsevier B.V. All rights reserved.

The creation of the Unified Health System (SUS) in Brazil, 25 years ago is based on progressive principles such as universal access, equity and comprehensive health care. A major initiative within this system is the “family health strategy” (ESF), concentrated in the provision of primary health care. In the past 10 years, the ESF has increased rapidly in less developed areas and reaches approximately 50% of the population (Barreto et al., 2014). The core ESF teams consist of physicians, nurses, nurse technicians, and community health workers (CHWs), who are lay community members

∗ Corresponding author. E-mail address: [email protected] (A.Y. Spector). http://dx.doi.org/10.1016/j.drugpo.2014.12.005 0955-3959/© 2014 Elsevier B.V. All rights reserved.

with basic training in health promotion and disease prevention. ESF teams are funded by the federal government and municipalities to deliver primary care services to individuals within communities impacted by chronic diseases, poverty and drug use, and operate in each municipality (Paim, Travassos, Almeida, Bahia, & Macinko, 2011). Drug use in Brazil is increasingly identified (Galduroz, Noto, Nappo, & Carlini, 2005; Pechansky et al., 2006) and ESF workers are on the frontline in affected communities and may identify individuals with drug use problems. Brazil’s SUS has two key elements of diffusion (i.e., widespread communication channels and a social system of service providers) (Rogers, 2003) that may advance the diffusion of, for example, drug use services. However, little to no research exists which aims to understand whether or not

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ESF workers, charged with primary care, are providing drug use prevention and/or treatment services. This paper examines secondary data from 262 ESF workers (e.g., physicians, nurses, and CHWs) in order to identify the factors that influence workers to offer: “drug prevention services” (i.e., drug use services), which may include referrals to 12-step support groups, formal substance use treatment, or to provide peer counseling, education, and/or spiritual counseling. Spiritual counseling, while variable, generally includes discussing God, encouraging religious observance, and/or prayer as a means of healing physical and/or psychological impairments. Spiritual counseling is culturally bound and in Brazil, may often reflect the beliefs and traditions of the dominant religion: Catholicism, while in other countries may be grounded in other religions. There is strong agreement in the literature that efficacy is merely one element of intervention development and evaluation. Effectiveness must be demonstrated in order to roll out interventions in “real world” conditions. The adoption and sustainment of efficacious interventions, across varied contexts; is needed in order to advance public health outcomes (Proctor et al., 2011). Implementation research signifies a shift of emphasis in public health research from merely demonstrating interventions’ effectiveness in controlled settings toward translatability, scalability, and sustainability in context. Implementing evidence-based health services developed in one context (e.g., well-resourced country) in another (e.g., developing country) brings about several challenges due to limited resources, incongruous cultural values, and differences in workforce capacity. Therefore, research aimed at understanding how to optimize the implementation of various health programs, interventions, and services, given distinct environments is underway worldwide (Norton, Amico, Cornman, Fisher, & Fisher, 2009; Schackman, 2010). While the ESF is available to all Brazilian citizens, commonly, residents in impoverished communities are visited by CHWs (and sometimes nurses and physicians) who offer education about preventing diseases (e.g., dengue, HIV) (Berkman, Garcia, MunozLaboy, Paiva, & Parker, 2005), family planning and to make referrals to individuals in need of care and/or monitoring for chronic health conditions (e.g., hypertension, diabetes) (Brownstein et al., 2005). CHWs also provide assistance with applying to the social program BOLSA FAMÍLIA, a direct cash transfer program for families in poverty (Rasella, Aquino, Santos, Paes-Sousa, & Barreto, 2013), and with the prevention of child abuse (Johnson et al., 2013; Victora et al., 2011). CHWs help residents access civic services like voter registration and obtain identification (Johnson et al., 2013; Victora et al., 2011). CHWs build trusting relationships with stigmatized and disenfranchised individuals by establishing rapport, demonstrating honesty, persistence and empathy (Zanchetta, Salami, Perreault, & Leite, 2012). CHWs themselves are stigmatized given their low status as compared to physicians and nurses, their low wages, and the fact that they often come from the same communities (Abbatt, 2005). Because CHWs have been shown to integrate a wide array of services along with the provision of primary care (Pinto, Wall, Yu, Penido, & Schmidt, 2012), they represent an ideal workforce to help identify and address drug use in local communities, particularly among populations burdened by chronic diseases such as HIV (Simoes, Bastos, Moreira, Lynch, & Metzger, 2006) and compromised by social conditions, such as poverty, low education, and family violence (Cardoso & Verner, 2007). Drug use is intrinsically connected to the HIV epidemic in Brazil since drug users are at increased risk for transmission through unprotected sexual contact and, for injection drug users (IDU), through needle-sharing (Malta et al., 2010). Notably, however injection drug use has declined substantially in Brazil and a corresponding decrease in HIV among IDUs has been documented (Bastos, 2012).

Despite the National Health Law (Lei Organica, 1990) which stipulates universal access to drug use treatment, harm reduction, and education, in practice, the criminal justice system has become Brazil’s key approach to addressing drug use (United Nations Office for Drug Control and Crime Prevention, 2002). The number of inmates held on drug trafficking charges has increased 30%, from 106,491 in 2010 to 138,198 in 2012, and accounts for 25% of the overall prison population (United Nations Office on Drugs & Crime, 2013). Access to treatment remains relatively low, particularly for low-income populations without access to transportation or other resources (e.g., child care, income support). Drug treatment services sponsored by the Ministry of Health are offered through the Psychosocial Care Center for Alcohol and Drug Abuse (CAPSAD). The treatment activities offered under CAPSAD include individual care, group care (support groups), therapeutic workshops, home visits, rest and outpatient detox (Peixoto et al., 2010), however the availability of these services varies by geographic region and municipality. Therefore individuals in rural, poor, and less well-resourced municipalities may not be able to access some or any of these services readily. Interestingly, despite the low prevalence of injection drug use as compared with cocaine use, needle/syringe exchange programs (NSEPs) have remained relatively accessible with over 150 such programs operating as of 2006 (Bastos, 2012). The presence of such programs has been credited with the reduction of HIV among IDUs. CHWs in the ESF teams can help diffuse interventions and thus reduce drug use and the harms associated with drug use including morbity, mortality, and loss of productivity, and other social problems, across Brazil (Pinto, da Silva, & Soriano, 2012). Specifically, CHWs may leverage their role as frontline workers with access to individuals in their communities to identify those with drug use or drug dependence issues. They may be able to offer referrals based upon their assessment of need. CHWs may be trained in brief evidence based interventions like Motivational Interviewing to help their clients take the necessary steps to initiate treatment. CHWs may also offer supportive counseling and psychoeducation to clients and their families about drug use. Thus, the Ministry of Health launched a new strategy in 2013–2014 called “Caminhos do Cuidado”, which will train all CHWs and a nursing assistant or technician from each ESF team on the best and most efficient practices and procedures to serve individuals using drugs (Brazilian Ministry of Health, 2013). To help close the gap between the discovery of new interventions and their actual delivery and sustainment in community contexts (Proctor, 2004; Proctor et al., 2011), we hope this study contributes to an understanding of the implementation of this new initiative. To that end, we seek to establish whether or not ESF workers are already providing drug use services and to reveal the characteristics influencing drug use service delivery. This is crucial for the implementation of new initiatives for the ESF workforce, and particularly for Caminhos do Cuidado.

Factors that influence providers’ delivery of services Providers’ delivery of services is influenced by an amalgam of indigenous knowledge, training, environmental constraints, support from colleagues, attitudes, and beliefs. CHWs especially rely upon indigenous knowledge, local resources and their limited technical training to communicate empathically while providing education and counseling (Pinto, da Silva et al., 2012). Providers’ professional discipline or job role (e.g., nursing), understanding of the local community, and collaboration with colleagues from other disciplines are associated with integration of services like including drug use services with primary care interventions (Pinto, da

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Silva et al., 2012). CHWs and nurses have been shown to integrate different services (e.g., psychosocial and medical) more so than physicians (Pinto, da Silva et al., 2012). Drug use treatment providers who are aware of evidence-based practice (EBP), and those that work in settings that support the use of research to guide practice, integrate medical and psychosocial treatments (Aarons & Sawitzky, 2006; Pinto, Spector, Yu, & Campbell, 2013; Pinto, Yu, Spector, Gorroochurn, & McCarty, 2010). Therefore, this paper examines providers’ awareness of EBP, such as following protocols and accessing new information, their perceptions of peer support from colleagues, and their access to resources like training, assessment and treatment tools, as well as their job role as predictors of drug use service delivery. Advances in addiction treatment research have yielded pharmacological interventions (e.g., methadone, buprenorphine, naltrexone) and behavioral interventions (e.g., cognitive-behavioral therapy, motivational interviewing, contingency management). In the United States, these interventions have been diffused widely (Pinto et al., 2010, 2013). However, it is unclear to what extent these evidence-based interventions are or will ever be available in Brazil to individuals in poor communities. For example, only two medications for addiction are listed with the Brazil’s Ministry of Health Relac¸ão Nacional de Medicamentos Essencias, the national listing of pharmaceuticals offered: methadone and nicotine replacement. However, access to those medications varies according to funding and by geographic location. Drug users may hesitate to seek treatment for fear of criminal prosecution and/or for lack of financial or social resources such as transportation or childcare (Cruz et al., 2014). Drug users may not be aware of effective treatments, perceive that the quality of services offered is poor and assume that they will face stigma and discrimination. Twelve-step peer support groups like Alcoholics/Narcotics Anonymous in Brazil are gaining popularity since any one can attend free of charge. However, many drug users still are not aware of how to access them or may be hesitant to do so because of fear of loss of confidentiality (Cruz et al., 2013a,b).

Theoretical framework This study is guided by social cognitive theory, which states that human beings achieve goals socially through sharing knowledge, skills and resources. They work collaboratively and supportively in order to achieve that which they would be unable to do on their own. Social cognitive theory conceptualizes various forms of agency as the driving force behind providers’ delivery of services (Bandura, 1989). ESF workers are engaged in transdisciplinary collaboration (Pinto, da Silva et al., 2012) and are thus influenced by various forms of agency as follows. Personal agency is represented by ESF providers’ job role, professional training, and their knowledge of EBP. Proxy agency is comprised of peer support from colleagues with whom ESF workers share and exchange information, tasks, and responsibilities, and with whom they may consult about cases. Collective agency is represented by resources shared among ESF teams, including training and tools (e.g., assessments). Therefore we have included variables in our model that represent personal, proxy and collective agency. We hypothesized, based upon both this theory and published empirical papers, that workers with knowledge of the local community (i.e., CHWs), knowledge of EBP, workers that believe they have adequate resources and training to deliver EBP, and those that report a high level of support from colleagues would be more likely to offer drug use services than their peers (Glisson, 2007; Pinto, da Silva et al., 2012). Workers whose actions are grounded in personal, proxy, and collective agency are most prepared to respond to the changing cultural environment, where drug users are in urgent need of services.

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Methods Sample and data collection As part of a study that developed out of a partnership between US-based and Brazil-based researchers, this study was based upon pilot work that included qualitative interviews with providers and stakeholders in the ESF. Based upon this pilot work a survey was developed to better understand the provision of services in the ESF. For details see Pinto, Wall et al. (2012). Data were collected in the ESF in two municipalities: Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State. Survey questions focused on how ESF workers deliver services, educate communities on prevention strategies, raise awareness of social, health and environmental issues, and on their perceptions about research and EBP. Surveys were collected from 10 units in Mesquita and 20 units in Santa Luzia. In each unit, we recruited at least 1 physician, 1 nurse, and 1 CHW to make certain to capture at least one representative of the SUS basic transdisciplinary unit. Participation was voluntary, and participants received refreshments. Nurses in each unit recruited participants. Approximately 85% of staff in all units participated leading to n = 262 participants (168 CHWs, 62 nurses, and 32 physicians). Eight master’s level Brazilian interviewers administered surveys using password-protected mobile computers. Participants were given information sheets about the study and potential risks and benefits. Instrument The survey was comprised of 118 questions including: demographics; awareness about local community issues; service integration; and opinions about research, EBP, and collaboration with colleagues. Surveys were translated and back translated from Portuguese to English to Portuguese using standard protocol. Measures The outcome variable was one item measured dichotomously, “Do you provide drug prevention services”. This question captured diverse types of services including: identification of individuals struggling with drug use, referral for treatment to psychosocial (e.g., counseling) or to medical (i.e., methadone) treatment, referral to peer support, providing peer counseling, education, and/or spiritual counseling. The question allowed for an open interpretation to capture as many types of drug use-related services as possible since this area of inquiry is new with no descriptive literature as of yet. Demographic characteristics Demographic characteristics included gender, age and job category. Gender was male or female. Age in years. Job category was measured as CHW, nurse, or physician. Predictors Principal components factor analyses were performed with Varimax rotation using SPSS software. Composites were developed based upon factor analyses. Scale analysis was performed and alphas were calculated to determine reliability of each composite. All alphas were greater than 0.60. These alphas are considered “reasonably good” (Cohen & Cohen, 1983) (p. 70) given that this is the first study of its kind using newly developed measures. Collective agency (ESF workers using tools (e.g., assessments, treatments) available to the teams). Capacity to engage in EBP was comprised of three items (alpha = 0.70) measured continuously on a 5-point Likert-type scale from strongly disagree to strongly agree (0–4): (1) “I have the tools necessary to make an assessment;” (2) “I have the tools necessary to deliver health services to the families”; and (3) “I have the tools necessary to evaluate outcomes”.

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Table 1 Provider characteristics by whether they offer drug prevention services. Characteristic

Age category 20–30 years 31–40 years 41–50 years 51–60 years 61–70 years Female Staff type CHW Nurse Physician a

Drug prevention (yes)

Drug prevention (no)

Percent

N

Percent

N

44 26 18 10 2 77.2

44 26 18 10 2 78

45.5 34.4 15.6 4.5 0.0 84.2

70 53 27 7 0 133

56.4 24.8 18.8

57 25 19

69 23.4 7.6

109 37 12

X2

p

7.398

.116

1.97 8.04

.108 .018a

Physicians were significantly less likely to offer drug prevention services than CHWs and nurses.

Resource constraints (gaps in ESF team workers’ available resources) was comprised of three items (alpha = 0.70), each measured continuously on a 5-point Likert-type scale from strongly disagree to strongly agree (0–4): (1) “With additional training, I would be more successful at meeting the needs of my clients”; (2) “With access to additional resources, I would be more successful at meeting the needs of my clients”; and (3) If I had access to colleagues of other professions, I would be more successful at meeting the needs of the families I serve”. Proxy agency (collaboration with colleagues in ESF). Peer support was comprised of three items (alpha = 0.60), each measured continuously on a 5 point Likert type scale from strongly disagree to strongly agree (0–4): (1) “Team meetings are important for the discussion of the families’ health problems”; (2) “Team meetings are important for the team in order to better plan families’ treatment”, and; (3)“I have access to colleagues when I need help determining interventions”. Personal agency (one’s knowledge of evidence based practice). Knowledge of EBP was comprised of three items (alpha = 0.60), each item measured continuously on a 5-point Likert type scale from strongly disagree to strongly agree (0–4): (1) “I can find the information I need to help my clients”; (2) “I know how to use new information to change the way I treat my clients”; and (3) “I am able to understand and use protocols to help my clients”. Statistical analysis We conducted descriptive analyses and correlation analyses for each demographic predictor variable. The results are reported in Table 1 and summarized below. Subsequently, demographics and predictor variables were entered into a logistic regression model in one step. Predictors of providing drug use services were examined using a logistic regression model. Predictors were categorized as demographics (i.e., age, gender, job category), knowledge of EBP, peer support, resource constraints, and capacity to implement EBP. Results are summarized in Table 2 and described below. Logistic regression was used to determine relative influence of each composite variable and each demographic variable, upon the binary outcome of whether workers reported offering drug prevention services. Results Thirty-nine percent of the sample reported providing drug prevention services. Breaking this down by job category there were 56.4% of CHWs, 24.8% of nurses and 18.8% of physicians that reported providing drug prevention.

Correlation analysis Chi square tests were conducted for each categorical demographic variable to determine whether there are significant correlations between demographics and the outcome. Age was recoded as a categorical variable represented in years as 20–30, 31–40, 41–50, 51–60, and 61–70. The percentage of participants that provide drug prevention did not differ by gender, X2 (1, N = 262) = 1.97, p = .11 or age X2 (4, N = 262) = 7.40, p = .12. However the percentage of physicians that offer drug prevention services was significantly lower than nurses or CHWs X2 (2, N = 262) = 8.04, p = .02. Regression Neither gender nor age was significantly associated with offering drug prevention services. Job category was significantly associated with drug prevention services; compared to CHWs and nurses, physicians were less likely to offer drug prevention (p < 0.05), OR = 1.31. ESF workers that report having knowledge about using EBP such as incorporating research findings, using protocols, and accessing new information were more likely to offer drug use services (p < .05), OR = 1.26 (e.g., counseling, treatment, referrals for support). ESF workers that report peer support, in the form of collaboration through ESF team meetings and access to colleagues, in determining interventions for their clients were more likely to offer drug use services (p < .05), OR = 1.26. ESF workers that reported resource constraints (lack of professional training, access to colleagues, and tools/equipment) were less likely to offer drug use services (p < .05), OR = 1.84. Workers that

Table 2 Logistic regression model. Outcome variable: provides drug use services. B Standard error Age (in years) −0.24 (0.15) Job category (CHW is reference group) −0.14 (0.36) Nurse −1.17 (0.48)* Physician 0.40 (0.38) Gender (male/female) Predictors 0.23 (0.09)* Knowledge of EBP 0.23 (0.11)* Peer support −0.17 (0.09)* Resource constraints Capacity to implement EBP −0.28 (0.09)** * **

p < .05. p < .005.

P-values

OR

0.11 0.70 0.01 0.30

1.31

0.01 0.04 0.05 0.001

1.25 1.27 1.84 1.75

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reported having more capacity to implement EBP (access to tools to assess, treat, and evaluate their clients) were also less likely to offer drug use services (p < .05), OR = 1.75. In unadjusted regression analyses the result remained significant (p < .05) in the negative direction. Discussion Implementation research holds promise for studying and evaluating the key elements of diffusion in Brazil’s ESF. We examined factors associated with ESF workers’ providing drug use services. This represents an important step coinciding with the roll-out of the new national health workforce training “Caminhos do Cuidado” which will focus on training ESF teams in identifying and making referrals to drug use services. Our next step will be to examine the “acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration, and sustainability” of the “Caminhos do Cuidado” initiative. While the ESF is intended to provide universal coverage, in 2013 the program covered only 56.37% of the population. Individuals that also have private health insurance are less likely to use this program and it remains a lifeline for low-income individuals. Likewise, ESF workers are tasked with reaching large numbers of people with limited staff and budgets that fluctuate depending on changing political administrations and priorities of elected officials. As of 2008, 27,000 ESF teams were active in nearly all of Brazil’s 5560 municipalities (Jurberg, 2008). That number rose in 2013 to 35,242 active teams (Ministério da Saúde, 2013). Through collaboration among colleagues across professions (transdisciplinary collaboration) (Pinto, da Silva et al., 2012), ESF teams have been effective in reducing HIV transmission rates, increasing immunization rates, and reducing infant and child mortality (New York University, 2006; Victora et al., 2011). At the same time, collaboration amongst professionals from different disciplines is complicated, since municipalities cultivate distinct organizational cultures within their ESF teams. Some ESF teams evidence a flat organizational structure where there is peer support and open dialogue between all professionals, regardless of status, with special attention given to the CHWs, who are viewed as experts of the community. Other ESF teams operate in a more hierarchical fashion, privileging the physicians’ or nurses’ voices over CHWs’ (Zanchetta et al., 2009). Criticisms have been raised that physicians in the ESF are not as adept as other workers (for example, CHWs) at demonstrating empathy and communicating effectively with community residents (Brownstein, Hirsch, Rosenthal, & Rush, 2011). ESF provider age was not associated with offering drug use services. Previous research however, shows that younger workers are more likely to endorse evidence-based practices than older workers. Younger workers, by virtue of more recent training, may be familiar with advances in drug treatment and may be aware of how to identify drug use. Updated training for older ESF providers may be enhanced by younger providers, through proxy agency (Bandura, 1989) by contributing to peer consultations and developing training for their colleagues. Workers with higher levels of personal agency are able to access research, new information and incorporate protocols, and thus may actively seek current information about drug use. Workers that are aware of EBP may therefore understand drug use in the context of public health, rather than as a personal failing or criminal behavior. Therefore, personal agency in the form of enhanced individual capacity to locate, access, and appropriately integrate advances in drug use treatment may be a target of the interventions currently being rolled out with the ESF workforce (e.g., Caminhos do Cuidado). Workers with collective agency collaborate with colleagues over the course of team meetings and peer supervision and were more likely to offer drug use services. Having access to diverse

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professionals may augment exposure to new interventions and discoveries related to drug use treatment and prevention. Conversely, lacking access to colleagues may be an impediment. Workers with low collective agency may feel ill-equipped to offer drug use services. Transdisciplinary collaboration (i.e., professionals from diverse disciplines working toward common patient outcomes) has been shown to improve services related to primary care, drug use, HIV treatment, and mental health care (Centers for Disease Control & Prevention, 2009; Dankwa-Mullan et al., 2010; Dyer, 2003; Fuqua, Stokols, Gress, Phillips, & Harvey, 2004; Pinto et al., 2013). Relatedly, workers that seek out their colleagues may also themselves be reflective, insight-oriented and open to input; characteristics that may be facilitators to their ability to work collaboratively in teams for the benefit of the populations they serve. Therefore, future research should aim to uncover how to best foster collaboration among ESF teams in the context of changing political environments and shifting resources. Popular education, a method to increase CHWs’ capacity to resolve problems and foster empowerment (Wiggins et al., 2009) may provide a framework for devising interventions aimed at bolstering collaboration in ESF teams. Surprisingly, workers that reported having the necessary tools to assess, treat, and evaluate their clients were less likely to offer drug use services. Perhaps workers that report having the necessary tools to assess, treat, and evaluate their clients consider drug use services to fall outside the realm of assessment, treatment and evaluation and therefore avoid the practice. This represents a limitation of how the outcome question was phrased, in that certain ESF workers may interpret drug prevention as a very specific type of service (that they are not qualified to deliver) versus the delivery of routing primary care (Schmidt, Clecy, personal communication). Lacking training in drug use treatment, ESF workers may choose instead to focus on that which they feel equipped to manage. This is consistent with the Social Cognitive Theory, which suggests that not having adequate knowledge or training would hinder a practice. Our findings suggest that ESF workers require education about how to use new information and research in order to deliver drug use services. Locating, assessing and evaluating the latest research should become part of training for all workers in the ESF. Since some workers are already adept at this, there is a natural source of mentorship and peer support for those workers for whom evidence base practice represents a new approach. Physicians appear to be the most likely to have access to innovations and be able to bring their knowledge to team meetings (Schmidt Clecy, personal communication). Developing strategies for collaboration among colleagues through team meetings, peer supervision and collaborative treatment planning may enhance workers’ delivery of drug use services, regardless of professional discipline. Limitations Limitations of this study include the cross-sectional design, which does not allow us to look at changes over time, and the lack of directly observable measures. It would be useful to objectively measure workers’ EBP knowledge and their actual delivery of services in order to validate the self-reported predictors and outcomes. Also, the sample came from two regions in Brazil and may have some selection bias since those particular regions were willing to participate. However, since the SUS mandates and funds uniformly transdisciplinary teams (CHWS, physicians and nurses), we believe that our findings shed light on the issue of drug service provision in other areas of the country. Nonetheless, ideally, future samples of ESF workers ought to be larger and include diverse geographic regions. The participants in this study included primary care providers; physicians, nurses and CHWs. There were no pharmacists, or other

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specialists in this sample, which focused upon examining those professionals most frequently involved in routine patient care, care coordination and interdisciplinary collaboration. Pharmacists, dentists, psychiatrists and other specialists are important providers of services that complement the work of primary care providers. Future studies ought to focus upon examining the practices of specialists like pharmacists on ESF teams. This paper aims to examine key factors that influence ESF workers to offer drug use services in poor communities served by SUS and cannot shed light on the portion of the population (approximately 40%) who have private health insurance and enjoy greater access to effective medical and mental health care in general through privately run clinics and hospitals. Measurement limitation: ESF workers are likely not addressing pre-emptively, drug use issues with individuals who are not yet using drugs, which is how prevention may be understood in some contexts. Rather ESF workers are preventing harm from drug use by identifying those in need of drug treatment and connecting them with the appropriate resources. Future studies should examine ESF workers’ delivery of specific intervention for the prevention and treatment of drug use, over time, particularly in order to evaluate the impact of Caminhos do Cuidado. Mixed methods including surveys and qualitative interviews may help to shed light on how ESF workers integrate their training in drug use services with their delivery of primary care, social and civic assistance. Likewise, ethnographic methods like participant observation may further shed light on the unique contribution of diverse professionals on ESF teams toward client outcomes and to transdisciplinary collaboration during team meetings and peer consultations. Drug use continues to be stigmatized throughout the world through both criminal penalties and social ostracism and disenfranchisement. Community service providers have the capacity to identify, engage with and offer supportive services to drug users. However, providers need support in order to overcome the challenges of delivering effective services with limited resources, to a population that is highly stigmatized, often misunderstood, and that has a high rate of relapse. By identifying factors associated with providers’ delivery of drug use services, the current study has implications for optimizing this workforce’s ability to help curb drug use in Brazil. Acknowledgments Dr. Spector is a postdoctoral fellow supported by a training grant from the National Institute of Mental Health (T32 MH19139, Behavioral Sciences Research in HIV Infection; Principal Investigator: Robert H. Remien, Ph.D.) at the HIV Center for Clinical and Behavioral Studies (P30 MH 43520; Center Director: Robert H. Remien, Ph.D.). Data for this manuscript was supported by Columbia University School of Social Work. Dr. Pinto was supported by a National Institute of Mental Health Mentored Research Development Award PI: Rogerio M. Pinto (K01MH081787-02). The authors wish to acknowledge Dr. Melanie Wall for her invaluable consultation and feedback. Conflict of interest None declared. References Aarons, G. A., & Sawitzky, A. C. (2006). Organizational culture and climate and mental health provider attitudes toward evidence-based practice. Psychological Services, 3(1), 61–72.

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Implementation of Brazil's "family health strategy": factors associated with community health workers', nurses', and physicians' delivery of drug use services.

Brazil's "family health strategy" (ESF), provides primary care, mostly to individuals in impoverished communities through teams of physicians, nurses,...
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