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

全球土著人民的健康和生活条件比非土著人民更差。历史、社会和政治力量是关键因素，但薄弱的卫生系统也有助于解释这一现象。青少年健康很重要，是进行干预的适当时机。这对土著社区至关重要，因为与非土著社区相比，土著社区向成年的过渡要快得多，有更早的养育和照顾责任。2017年联合国高级别政治论坛概述了巴西的卫生优先事项，包括非传染性疾病和由外部原因（特别是暴力）引起的疾病，重点关注可持续发展目标1、2、3、5、9和14，以及“在不断变化的世界中消除贫困和促进繁荣”的中心主题。对这些国家的土著人民来说，这一点最为贴切，因为他们的子女面临着社会不公正和健康状况不佳遗留下来的挑战。巴西有约100万土著居民，其中约50%年龄在24岁以下。南马托格罗索州（Mato Grosso do Sul）是拟议研究的地点，拥有第二大原住民密度（7万人），其中70%的人年龄在20岁以下。巴西对土著居民的卫生系统进行了大量的思考和投资，但土著居民的健康状况仍然落后于非土著居民。根据在其他国家环境中取得的有效性证据，社区卫生工作者是改善土著卫生系统的一个机会。我们会在使用健康护理中心的学校共同设计一项干预措施，提供普及和有针对性的健康促进、健康问题筛查和早期干预服务。我们将与当地土著青少年、教师和保健专业人员合作，设计干预和评价的内容。我们将进行调查，以审查哪些程序最有效，以及它们如何加强土著初级保健系统。为了评估保健员的影响，我们将收集满意度和健康素养的数据。我们亦会收集有关健康结果的资料，这些资料连同这项研究的其他结果，有助我们计划日后就学校健康护理服务的成效进行大规模研究。这项新的和重要的研究将帮助我们探索如何帮助土著青年避免他们的父母和前几代人所经历的疾病。

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.