Capacity-building in family health

Primary care reform in Brazil and Chile

The structure of primary care delivery systems in Chile and Brazil actively supports the provision of interdisciplinary care, and primary care teams are responsible for the needs of the population of defined geographic areas, as shown in Table 1.

In Brazil, most primary care is provided by interdisciplinary teams, with a ratio of approximately 1 team per 4000 people in a defined area.11,12 These teams monitor the health status of the communities where they work. This process has evolved over the past 15 years and is now the basic structure of the health care system. Canada, however, does not restrict care provision on a geographic basis; therefore, primary care providers located in urban areas, unlike their counterparts in rural settings, cannot clearly define geographic communities to which they provide services (unlike providers in rural areas). There are more primary care physicians per capita in Canada than in either Chile or Brazil, and therefore physicians in Canada have generally been the core of primary care services, whereas the latter countries use more of a team approach to providing comprehensive services (eg, 29300 family health teams in Brazil).

Program description

In 1995, the DFCM at the University of Toronto initiated a program to train PHC teams in Brazil. A few years later, in 1999, the program expanded to include interdisciplinary training provided in Toronto for Chilean PHC teams.13

This 5-module program (Table 2) used participatory educational methodology14,15 and targeted primary care providers from various disciplines with at least 3 months of front-line experience. The program was offered in 2 formats: intermittent “in-country” training or an intensive course taught in Canada. In Brazil, the in-country course took place over a period of 8 to 12 months, during which 5 modules of 2 to 3 days each were interspersed with 2-month “action periods.” The Canadian program was delivered to Chilean participants in Toronto, with 3 modules offered to groups of 12 to 20 PHC professionals over a 6-week period. The educational methodology combined short didactic presentations, whole group learning exercises, and small group problem-based learning sessions, including team projects that were completed between each module and presented at the beginning of the next one. During the course, the participants learned how to perform computer database searches and assess the best evidence in the management of common problems.

In Brazil, in addition to the direct training of front-line workers, the program also invited local authorities and universities to support participants in their study projects and assist the students with access to libraries and resources. These supportive institutions learned about the needs of front-line professionals, helping them to inform development of future graduate and postgraduate programs. The model had a train-the-trainer component and enabled the training of a large number of professionals in a short period of time. In the initial phase of the program, the Canadian team trained 15 professionals from medicine, nursing, and dentistry. This group, in turn, facilitated the training of more than 3000 professionals in Brazil over a period of 10 years.

Program content

To achieve program objectives, participants formed teams to complete 3 group projects through which they developed 3 sets of skills: using evidence to improve quality of clinical services, engaging communities in health promotion projects, and working with families in clinical and community-based settings. In addition, each project included an implementation and evaluation strategy, with clearly defined roles for each team member. All teams arrived at the course with lists of the health problems commonly seen in their communities, which were used as the basis for their work.

The 5 modules

This was a 5-module program (Table 2). The first module, which began with an overview of the principles of family health, focused on clinical competence and the use of evidence. Each team identified a clinical problem in its population and, following bibliographic searches for the best evidence on the subject, presented a plan to develop a care pathway. The care pathway outlined the role of each team member involved.

The second module focused on the team as a resource to the community and the skills required by the professional to assess community needs and identify risks. It taught students to maintain their skills and knowledge as lifelong learners, to evaluate the quality of their services (ie, audit), to act as advocates, to promote community health, and to maintain their own well-being.16,17 Each project included a detailed description of the role of each professional on the team.

For the third module, each group developed a plan to produce a profile of the structure of families in the community served by its clinic. Each team also selected a particular family that clinic workers found challenging. Each team assessed the problems of its “family” in detail, using various tools (eg, the genogram, ecomap, and life cycle) presented during training, in order to understand the family’s problems and possible root causes. Next, integrating the learning from the previous 2 modules, the team developed an interdisciplinary strategy to work with family members to address key problems as well as important risk factors.

The fourth and fifth modules focused on adult education and effective educational strategies. The objective of these modules was to train the participants to teach the first 3 modules under the supervision of another group of PHC teams, as part of the multiplier component of the program. These modules have been mainly taught in Brazil, where teaching occurs on-site.

Program evaluation

In order to assess the training initiatives in Brazil and Chile, the interprofessional unit and the DFCM combined data from prior qualitative and quantitative studies,18,19 which were inspired by Kirkpatrick’s model of educational outcomes.

Table 319,20 outlines the indicators that demonstrate Freeth and colleagues’ educational outcomes on inter-professional development. Participants’ reactions, attitude modifications, and acquisition of new knowledge were assessed by informal discussions at the end of each module. Participants also completed preprogram and postprogram tests.

Team behaviour and attitudes were evaluated using a questionnaire based on the Schutz FIRO (Fundamental Interpersonal Relation Orientation) model of team functioning (ie, inclusion, influence, and openness) at the end of each project and at the end of the course.21

Conclusion

The implementation of a team-training program for PHC professionals over a 12-year period demonstrated the need for a curriculum grounded in the learners’ direct experiences in the field; their own needs to function as a PHC team; and the needs of the communities they serve. It has also been shown that a solid commitment to PHC by the government of the program participants is central to the sustainability of the reform.