Brazil's Community Health Workers Practicing Narrative Medicine: Patients' Perspectives.

BACKGROUND: Narrative medicine (NM) encourages health care providers to draw on their personal experiences to establish therapeutic alliances with patients of prevention and care services. NM medicine practiced by nurses and physicians has been well documented, yet there is little understanding of how community health workers (CHWs) apply NM concepts in their day-to-day practices from patient perspectives. OBJECTIVE: To document how CHWs apply specific NM concepts in Brazil's Family Health Strategy (FHS), the key component of Brazil's Unified Health System. DESIGN: We used a semi-structured interview, grounded in Charon's (2001) framework, including four types of NM relationships: provider-patient, provider-colleague, provider-society, and provider-self. A hybrid approach of thematic analysis was used to analyze data from 27 patients. KEY RESULTS: Sample: 18 females; 13 White, 12 "Pardo" (mixed races), 12 Black. We found: (1) provider-patient relationship-CHWs offered health education through compassion, empathy, trustworthiness, patience, attentiveness, jargon-free communication, and altruism; (2) provider-colleague relationship-CHWs lacked credibility as perceived by physicians, impacting their effectiveness negatively; (3) provider-society relationship-CHWs mobilized patients civically and politically to advocate for and address emerging health care and prevention needs; (4) provider-self relationship-patients identified possible low self-esteem among CHWs and a need to engage in self-care practices to abate exhaustion from intense labor and lack of resources. CONCLUSION: This study adds to patient perspectives on how CHWs apply NM concepts to build and sustain four types of relationships. Findings suggest the need to improve provider-colleague relationships by ongoing training to foster cooperation among FHS team members. More generous organizational supports (wellness initiatives and supervision) may facilitate the provider-self relationship. Public education on CHWs' roles is needed to enhance the professional and societal credibility of their roles and responsibilities. Future research should investigate how CHWs' personality traits may influence their ability to apply NM.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey.

BACKGROUND: HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing. METHODS: Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey. RESULTS: Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing. CONCLUSIONS: Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

Community health agents, nurses and physicians conducting research in Brazil's family health program.

While the integration of community-based providers within interprofessional health teams has been recommended by policymakers worldwide, there is limited research on how medical and community-based providers inform and participate in health research. Our study uses cross-sectional data from 169 Community Health Workers (CHWs), 62 nurses, and 31 physicians within Brazil's Family Health Strategy Program. Using an integrated framework of social cognitive theories and Theory for Planned Behavior, a reliable and valid instrument was developed to examine differences in past research involvement, and opinions about health and public health research (research efficacy and perceptions of research process). Descriptive frequencies and ANOVA F-tests were performed. Results indicated that CHWs has greater mistrust in the research process, and were not involved in substantive aspects of research (specification of aims, data collection, analysis, dissemination). Nurses compared to CHWs recruited participants to research studies, and had greater willingness to learn, participate and implement research initiatives. Physicians compared to CHWs and nurses developed survey instruments and disseminated research. For community-based and medical providers to be involved in all aspects of research, researchers ought to set up structured infrastructures of community collaborative boards. Furthermore, researchers can test our scale with other providers working within health teams globally.

A client-centered relational framework on barriers to the integration of HIV and substance use services: a systematic review.

BACKGROUND: Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions. METHOD: Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers' and clients' perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy). RESULTS: Using a client-centered relational framework, we identified barriers in three relational domains with "the client" as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services. CONCLUSION: This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.

Delivery of Community-Based Care Through Inter-professional Teams in Brazil's Unified Health System (UHS): Comparing Perceptions Across Community Health Agents (CHAs), Nurses and Physicians.

Given the shortage of medical providers and the need for medical decisions to be responsive to community needs, including lay health providers in health teams has been recommended as essential for the successful management of global health care systems. Brazil's Unified Health System (UHS) is a model for delivering community-based care through Family Health Strategy (FHS) interdisciplinary teams comprised of medical and lay health providers-Community Health Agents (CHAs), nurses, and physicians. This study aims to understand how medical and lay health providers' perceptions and attitudes could impact the delivery of community-based care. The study compares perceptions and attitudes of 168 CHAs, 62 nurses, and 32 physicians across their job context, professional capacities, professional skills, and work environment. Descriptive and bivariate analysis were performed. CHAs reported being the most efficacious amongst the providers. Physicians reported incorporating consumer-input to a lesser degree than nurses and CHAs. CHAs reported using a lesser variety of skills than physicians. A significant proportion of physicians compared to CHAs and nurses reported that they had decision-making autonomy. Providers did not report differences that lack of resources and poor work conditions interfered with their ability to meet consumer needs. This study offers technocratic perspectives of medical and lay health providers who as an inter-professional team provide community-based primary health care. Implications of the study include proposing training priorities and identifying strategies to integrate lay health providers into medical teams for Brazil's Unified Health System and other health systems that aim to deliver community-based care through inter-professional health teams.

Factors that Influence Co-production among Student Interns, Consumers, and Providers of Social and Public Health Services: Implications for Interprofessional Collaboration and Training.

Providers of public health and social services ("providers") develop and deliver services by engaging in interprofessional collaboration (IPC), from seeking external advice to making referrals and linkages to various social and public health services. Providers collaborate with consumers of social and public health services ("consumers") and student interns (e.g., social work, public health) to explore, determine, and deliver relevant services through a process referred to as co-production. Both IPC and co-production are widespread strategies with the potential to improve service accessibility and quality. However, the intersection of co-production and IPC remains understudied. This study examines factors that influence co-production in IPC among service providers, consumers, and student interns. We used cross-sectional survey data from an NIMH-funded study, including 379 providers in 36 HIV-service organizations in New York City. We examined the relationships between providers' perspectives on co-production in IPC and multiple provider- and organization-level variables using random-effects logistic regression. Most respondents said that consumers and students in their agency participate in IPC on the issues that concern them. Providers who perceive greater flexibility in the IPC process were more likely to agree that their organizations' providers co-produced IPC. Organizational service offerings (i.e., multilingual services, a comprehensive range of services), job positions, and full-time employment status were strong predictors of co-production. Our findings indicate that intentional and inclusive models of flexible IPC are needed. Fostering co-production in the HIV service field requires more institutional support and incentives for organizations, providers, and student interns. Implications for research and practice are discussed.

Examining Interprofessional Collaboration across case managers, peer educators, and counselors in New York City.

Many individuals who are vulnerable to HIV infection and People Living with HIV (PLWH) experience fragmented prevention and care. Prevention and care service integration, pivotal for the HIV care continuum, depends on relationships among service providers and agencies offering HIV services. Case managers, counselors, and peer educators often work together to provide integrated services through interprofessional collaboration (IPC) in HIV prevention and care. Although these providers have distinct job titles, they typically offer complementary services on the HIV care continuum. To better train and allocate professional development resources for these providers, research is needed to assess the overall differences between provider-type and their demographics, intrapersonal factors, and job characteristics most likely to predict IPC engagement. We administered a cross-sectional survey to 75 counselors, 80 peer educators, and 112 case managers in 36 agencies in New York City. We performed a series of linear mixed effects models. Most of the HIV-service providers identified as Black and female and had been working for their agencies for less than a year. Knowledge and skills, self-efficacy, understanding of the community, and greater work hours (> 35 hours) were significant predictors of endorsement of IPC. Peer educators compared to case managers were more likely to reflect on the process as they provide myriad services. Eliciting perspectives from providers allows us to explore interventions, both intra-agency (trainings, greater exposure to collaborative initiatives, and supervision) and interagency (retention programs and websites promoting provider collaboration), that could facilitate IPC engagement and integrated services across the HIV care continuum.

PluriVox Program in Brazil's Unified Health System: five-step group work to promote patient health behaviors / Programa PluriVox no Sistema Único de Saúde do Brasil (SUS): cinco passos na facilitação de grupos para promover nos usuários comportamentos de saúde

ABSTRACT This paper describes PluriVox, a user-friendly program aimed to improve group process and dynamics and to promote the health of undeserved population. PluriVox is grounded in psychoeducation, and it can be used in public health efforts to encourage service consumers ("patients") to become more active in realizing their own health-related needs through participation in health promotion groups. We suggest PluriVox as a strategy to help service providers (e.g., physicians, nurses, community health workers) and consumers to work as co-producers of health. PluriVox contains five competencies to help group facilitators: (1) observation protocol; (2) strategies to support group facilitation; and (3) group facilitator training. Training uses participatory methods that take only 15 hours. Herein we provide a description of how PluriVox was developed using group work theories. A preliminary evaluation suggests that PluriVox has potential to improve health professionals' capacity to facilitate health promotion groups in a Unified Health System

RESUMO Este artigo tem por objetivo apresentar o Programa PluriVox, que é uma estratégia de trabalho em grupos, de fácil aprendizagem e execução. O programa se destina aos grupos psicoeducativos realizados na saúde pública, e como finalidade a promoção, nos usuários, de protagonismo e corresponsabilidade na produção de saúde. O PluriVox é composto por cinco competências para facilitadores de grupos, baseadas em um protocolo de observação, estratégias de apoio para facilitação de grupos e um exemplo do processo de capacitação das competências por meio de metodologia participativa que pode ser executada em 15 horas. Descreve-se o processo de construção do PluriVox e discutem-se as teorias de facilitação de grupos. A avaliação da capacitação possibilita afirmar que os profissionais de saúde capacitados tornam os grupos um método de produção de saúde e que o PluriVox pode atender às necessidades do Sistema Único de Saúde, no que se refere aos grupos

Brazilian community health agents and qualitative primary healthcare information.

AIM: The aim of this study was to explore female community health agents' views about the value of recording qualitative information on contextual health issues they observe during home visits, data that are not officially required to be documented for the Brazilian System of Primary Healthcare Information. BACKGROUND: The study was conducted in community primary healthcare centres located in the cities of Araçatuba and Coroados (state of São Paulo) and Rio de Janeiro (state of Rio de Janeiro), Brazil. METHODS: The design was a qualitative, exploratory study. The purposeful sampling criteria were being female, with a minimum of three years of continuous service in the same location. Data collection with 62 participants was conducted via 11 focus groups (in 2007 and 2008). Audio files were transcribed and submitted to the method of thematic analysis. Four themes guided the analysis: working with qualitative information and undocumented observation; reflecting on qualitative information; integrating/analysing quantitative and qualitative information; and information-sharing with agents and family health teams. In 2010, 25 community health agents verified the final interpretation of the findings. FINDINGS: Participants valued the recording of qualitative, contextual information to expand understanding of primary healthcare issues and as an indicator of clients' improved health behaviour and health literacy. While participants initiated the recording of additional health information, they generally did not inform the family health team about these findings. They perceived that team members devalued this type of information by considering it a reflection of the clientele's social conditions or problems beyond the scope of medical concerns. Documentation of qualitative evidence can account for the effectiveness of health education in two ways: by improving preventative care, and by amplifying the voices of underprivileged clients who live in poverty to ensure the most appropriate and best quality primary healthcare for them.

USING SOCIAL NETWORK INTERVENTIONS TO IMPROVE MENTALLY ILL CLIENTS' WELL-BEING.

This paper reviews empirical evidence showing that the structures of the social networks of mentally ill clients influence both their well-being and their use of mental health services. Network interventions that might help clients better address network-related problems, and might help their families improve relationships and prevent caretaker's burn-out are presented. A case illustration will demonstrate how practitioners can assess a client's social network, involve the client's family in treatment, evaluate that treatment, and select tailored interventions. This case will emphasize both how practitioners can help a client restructure her network, and the complementary roles of formal and informal networks. The author shows practitioners how to match clients' initial network structures to interventions and desired outcomes. Practitioners can thus help clients modify their social networks, increase the use of preventive services, and improve their well-being.