Strengthening the primary care system for adolescent indigenous health in Brazil: Integrating community health workers into the school setting

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Indigenous people all over the globe experience worse health and living conditions that non-indigenous people. Historic social and political forces are key factors but weak health systems also contribute to the explanation. Adolescent health is important, and represents an opportune time for intervention. This is of critical importance for indigenous communities, as the transition to adulthood is much quicker with earlier parenting and caring responsibilities compared to non-indigenous communities. Health priorities for Brazil, outlined in the United Nations High-Level Political Forum of 2017, include non-communicable diseases and diseases resulting from external causes (especially violence) with a focus on Sustainable Development Goals 1, 2, 3, 5, 9 and 14, and on the central theme "Eradicating Poverty and Promoting Prosperity in a Changing World". Nowhere is this more pertinent than for their Indigenous populations whose children face the challenge of a legacy of social injustice and poor health.There are ~1 million indigenous people in Brazil, of which ~50% is <24y. Mato Grosso do Sul, the location for the proposed study, contains the 2nd largest concentration of indigenous people (70,000), and 70% are <20y. A lot of thought and investment has gone into the indigenous health system in Brazil but health of indigenous people still lags behind non-indigenous people. Community health workers represent an opportunity for improving the indigenous health system, based on evidence of effectiveness in other country settings. We will co-design an intervention in schools using CHWs to deliver universal and targeted services for health promotion, screening for health problems and early intervention. We will work with the local indigenous adolescents, teachers, and health professionals to design the content of the intervention and evaluation. We will conduct surveys to examine what processes work best and how they works to strengthen the indigenous primary care systems. To assess the influence of CHWs, we will collect data on satisfaction and health literacy. We will also gather information on health outcomes, which together with the other findings from this study will help us plan future large scale studies of the effectiveness of CHWs in schools. This new and important research will help us explore how to help indigenous young people avoid the ill health that their parents' and generations before them have experienced.