Title: Predictors of service integration by Estratégia Saúde da Famí­lia transdisciplinary health teams in Brazil's Sistema Único de Saúde
Description: 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. This study investigated the influence of individual- and organizational-level factors, and job characteristics on service integration using 262 providers from the Estratégia Saúde da Famí­lia teams. Brazil's Sistema Único de Saúde is acknowledged worldwide as a model for studying integration as FHS transdisciplinary teams, which comprise of Community Health Agents (in Portuguese, Agentes Comunitário de Saudi or ACS), nurses, and physicians, are mandated to integrate services. Methods: Cross sectional data were collected from 168 ACS, 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. Multiple logistic regression analysis and Structural Equation Modeling (SEM) were used to identify salient job characteristics, individual- and organizational-level factors associated with the three measures of service integration and service integration in itself. Individual factors were measured by providers' confidence, knowledge and skills, community familiarity, perseverance, and efficacy of the FHS team.

Job characteristics were measured by transdisciplinary collaboration, provider's autonomy in making decisions, skill variety (ability to use a set of diverse skills); and consumer-input. Organizational factors were measured by work conditions and resources. Results: Majority of participants were ACS (64%); 24% nurses; and 12% physicians. Of the sample, 82% were females (n =214). The highest proportion of participants identified as pardo (multiracial; n= 123; 46%); 82 (31%) as white; and 54 (21%) as black or Afro-descent. The mean age was 34 (SD = 10); ranging from 20 to 70 years. Results from the multiple logistic regression indicated that pardo providers, ACS, providers with a caseload of more than 500 usuária (service consumers), reported greater perseverance, and less work methods autonomy had greater odds of offering HIV prevention services. Providers with higher levels of knowledge and skills, greater confidence and skill variety had greater odds of engaging in civil registration.

Providers who identified as pardo, had less than 5 years or 5 years of work experience with the FHS, reported higher levels of knowledge and skills and greater skill variety had greater odds of mobilizing communities. Providers with experience of 5 years or more reported more service integration. After accounting for all variables, community mobilization, HIV prevention, and civil registration were strongly correlated. The following variables positively influenced service integration: higher levels of knowledge and skills; greater discretion by the job to use a variety of skills, confidence, and perseverance. Greater work-methods autonomy and decision-making autonomy were negatively associated with service integration. No organizational-level factors influenced service integration. Conclusions: This dissertation initiates a conversation in the literature on a framework to studying service integration. Provider trainings globally should incorporate activities that enhance providers' confidence, perseverance, knowledge and skills, and ability to make decisions on the spot use diverse skills while integrating services.

While Brazil's FHS program endorses transdisciplinary collaboration as a process for providers to integrate services, transdisciplinary collaboration was not significant predictor. Greater research needs to be designed and implemented in collaboration with providers to assess their perceptions of transdisciplinary collaboration. Research going forward also needs to be conducted on how organizational level factors impact service integration.