Building a Multi-disciplinary Approach to Assessing the Quality of Healthcare in Brazil

Building a Multi-disciplinary Approach to Assessing the Quality of Healthcare in Brazil

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Project summary

Health is more than an absence of illness, and improvements in health are closely linked with social, political, and economic conditions. Yet, programming often focuses on quantity of interventions rather than the holistic quality of impact. WHO, the UN’s Millennium Development Goals, and USAID have all recognized the critical impact of multi- dimensional determinants on health and disease. Still lacking, however, is an integrated approach to measuring and evaluating the impact of public health interventions from a multi-disciplinary perspective.

The most populous country in Latin America with an emerging economy and diverse, complex society, Brazil is an important and model setting to study such questions. Vanderbilt University is uniquely poised to be a global leader in shaping this conversation due to a nucleus of expertise found only at Vanderbilt, through its renowned faculty in infectious diseases and global health (specifically in HIV/AIDS and tuberculosis), Brazilian studies, and survey research. Vanderbilt’s historic strengths in Brazilian studies have provided a competitive edge in recent NIH grant applications focused on Brazil and Portuguese-speaking African countries such as Mozambique, the repeated success of the Center for Latin American Studies in securing competitive U.S. Department of Education National Resource Center grants, and in securing multiple grants on race, inequality, and access to health from the U.S/Brazil Initiative.

Via an inter-disciplinary approach, this project will build upon individual cross-campus successes through the development of innovative new approaches to understanding the multi- dimensional causes, implications, and consequences of deficits in the quality of healthcare provision in developing countries. While our long-term objectives include the creation of a new paradigm of scholarly pursuits with a broad international reach, we will initially focus this project on Brazil, a country often exhibited as a model due to large-scale successes in its expansion of access to healthcare services via programs such as Bolsa Família (Family Stipend). This is contrasted with the little understood yet dismal evaluations that the Brazilian people give regarding public healthcare services, according to LAPOP’s surveys of the country. In this study we plan to ask three overarching questions: (1) what explains the gap in widespread access relative to strikingly low satisfaction with healthcare services?; (2) what societal implications does it have for democratic development?; and, (3) what cultural, economic, social and political factors facilitate or impede successful healthcare outcomes?

The project leverages the networks of researchers and institutional affiliations already secured by the Medical Center, the Center for Latin American Studies, and the Latin American Public Opinion Project (LAPOP). It provides a mechanism for graduate and undergraduate students to study and contribute to the development of a new public healthcare paradigm – one that advances our understandings of societal barriers and influences on quality healthcare and outcomes. The focus of this work will be the construction of a sophisticated and multi- disciplinary survey instrument designed to uncover new ways to define and measure the social, economic, and political causes and consequences that underlie disparities in healthcare experiences and outcomes. Vanderbilt University will provide leadership in the development of this new global paradigm and this will position us for interdisciplinary extramural research proposals that focus on poverty and health, within the context of political science, Portuguese language skills, Brazilian studies, and triangle partnerships between Vanderbilt and institutions in Brazil and Mozambique.

Significance

Individuals receiving healthcare services are embedded in social, economic, and political contexts that affect and are influenced by healthcare outcomes. Recent best-practice guidelines for healthcare provision emphasize the need to recognize this fact and, thus, to move from “silos to synergy.”2 A unique set of conditions is needed to develop fertile terrain for this type of transformative research effort. Such conditions exist at Vanderbilt: expertise on the epidemiology and treatment of HIV and tuberculosis; humanists and social science experts on Brazil to understand cultural and historical influences on behavior and policy; and experts on survey research (LAPOP) who have decades of experience designing surveys but have not yet branched into the study of public healthcare provision. This project will thus foster collaborations initially between departments in the College of Arts and Science, and in the School of Medicine, and ultimately include the Owen School and Peabody, by bringing them together to produce cutting edge research on the social and political factors affecting one of the most profound global healthcare challenges of this century: how can we identify the societal determinants of healthcare utilization and outcomes for improved policy and healthcare delivery?

By focusing first on HIV and tuberculosis in Brazil, results from this project will have immediate public health importance for epidemic control and transmission interruption in this country. This can be used as a model to study other diseases (including non-communicable diseases such as cardiovascular disease and obesity) and other developing world settings. The project will bring medical students, graduate students, and undergraduates into world-class research mentored by faculty across the university. In this research collaboration we will introduce new courses on the social determinants of public health in developing countries open to undergraduates, graduate, and professional students from both the medical and non-medical sides of the university, and open to individuals from our partner institutions in Brazil (housed under Latin American Studies and the Vanderbilt Institute for Global Health). Short-term metrics by which progress on this project will be measured are the following: (1) a series of workshops to be held by the collaborators in Fall 2015; (2) introduction of a course on social determinants of public health in developing countries to be taught in Spring 2016; (3) an extensive survey instrument to be developed and pre-tested by Summer 2016; and, (4) at least two grant applications to be developed by Fall 2016 to seek funding for implementation of the survey to both a national sample in Brazil and to the population of Rocinha, Brazil’s largest favela (slum) and the location of a joint program between Brazil’s Ministry of Health and Vanderbilt experts working on the treatment of tuberculosis and HIV.

In the medium term, we anticipate the following outcomes: (1) sharing of survey results with large US Government donors such as NIH, CDC, USAID and other foundations in order to solicit new extramural grants; (2) broaden the reach of what was learned in Brazil by the incorporation of those results into the Vanderbilt Institute for Global Health (VIGH) work in Mozambique; (3) dissemination of results through academic publications and other international forums; and, (4) improvement in the quality of healthcare provided in Brazil, and in the health of the Brazilian population.

Ultimately, the long-term goal of this project is to provide a springboard to a new multi- disciplinary institute, involving an extended group of faculty including those at the Owen School and Peabody, for example, on the topic of Healthcare Provision and Democratic Citizenship in Developing Contexts.

Background

The sixth largest economy, fifth largest country, and fifth most populous (200 million) nation in the world, Brazil is an emerging power—but with great economic, social, and health disparities across a diverse nation. With universal healthcare available, nearly 2 out of every 3 Brazilians report having accessed public healthcare services in the past year. Yet, Brazilians identify deficiencies in public services as the most serious problem facing the country, and 3 of every 4 Brazilians express dissatisfaction with public health services (LAPOP data 2014). Given its size and regional importance, Brazil has been one of Latin America’s most prominent focal points of the spread of HIV/AIDS and tuberculosis over the past three decades. It has the largest estimated number of persons living with HIV in Latin America—approximately 700,000 adults and children. The HIV epidemic has been uniquely shaped by political and social forces in Brazil, including early availability of combination antiretroviral therapy, mounting a challenge to international trade laws, and changes in the patterns of HIV transmission. Brazil also has the highest number of tuberculosis cases in the Americas.

Since 2006, the Vanderbilt University School of Medicine has coordinated the NIH (NIAID)-funded CCASAnet (Caribbean, Central and South America network for HIV Epidemiology), including sites in Rio de Janeiro, São Paulo, and Minas Gerais, Brazil. Based on the success of this project, in 2013 the Regional Prospective Observational Research in Tuberculosis (RePORT)-Brazil cohort study was initiated, with funding from the NIH and the Brazilian Ministry of Health. RePORT-Brazil includes four study sites in Rio de Janeiro as well as sites in Salvador and Manaus. In 2014, the NIH also provided funding to study non- communicable diseases in HIV cohorts from 7 additional Brazilian sites (Coorte Brasil network). The current proposal will focus primarily on one of the RePORT-Brazil sites: Rocinha. Utilizing this geographically compact and densely populated neighborhood of the city of Rio de Janeiro we will examine social health determinants in an urban poverty setting. The choice of this site is practical, building on the already strong partnership in Rocinha, and also allows another way to advance research in this area as most research on healthcare provision in developing contexts is focused on rural areas rather than urban areas.

Vanderbilt’s College of Arts and Science is superbly qualified to generate a culturally- sensitive and scientifically validated survey of social determinants of health in Brazil. Vanderbilt is home to one of the top five programs in Brazilian studies in the United States with one of the strongest core faculties in the humanities and social sciences with a Brazil focus. These experts will play an important role in facilitating networking between the Vanderbilt investigators and institutions in Brazil; identifying cultural issues to address in the development of the survey instrument (e.g., issues of race and of traditional medicines/healers); and assisting with the translation of questionnaire items into Brazilian Portuguese. Under the leadership of Mitch Seligson and Elizabeth Zechmeister (Political Science), LAPOP has become the leading polling organization in the Americas conducting research in 28 countries. LAPOP is widely respected for the layers of expertise and quality control that it builds into all aspects of its projects: questionnaire construction, pre-testing, interview training, electronic data collection using specialized applications, fieldwork oversight, and data processing and analysis. With support from CNPq (Brazilian National Research Council) and other institutions, LAPOP has worked in Brazil since 2006. Yet while LAPOP’s surveys have included a limited set of questions on public healthcare services, LAPOP has not developed instruments for a robust study of healthcare delivery, outcomes, and evaluations. Given interest that has been expressed by the UN Development Project and others to LAPOP over issues related to healthcare provision and democracy, advancing in this area creates a platform on which LAPOP can contribute to cutting- edge multi-disciplinary research while also laying the foundation for grant applications to support future data collection. Linking LAPOP, VIGH, Brazilian studies, and other partners is a first step towards transforming our multi-disciplinary competitiveness in US-Brazil health research. Current collaboration between LAPOP and VIGH provide a mechanism by which to expand this project to other world areas over time.

 Project Stages

July-December 2015: The co-organizers will convene a series of meetings-as-workshops in Nashville to formulate a clear set of goals, criteria, and content for the proposed courses and survey development. Each workshop will address a different facet of a multi-disciplinary approach to public healthcare provision, in general, and/or in Brazil. For example, a great deal of sophisticated HIV and tuberculosis medical data collection has been going on for some time in Brazil and one workshop will focus on placing these medical data in their social and political context with in-depth surveys of patients and surveys of their communities. For some of these workshops, we will invite in researchers from others institutions – in particular, Brazil and Mozambique– to participate via Skype or Lync. The goal is to develop a holistic understanding of the social, economic, political, and health factors relevant to quality healthcare in developing countries; draw upon these discussions and experts to develop a syllabus for a course on this topic; and develop modules for the extended, multi-dimensional survey instrument. We will meet bi-weekly to maintain our collaborative momentum.

January-April 2016: In Spring 2016, we will offer a course open to both undergraduate and graduate students on understanding the societal strengths and challenges of public health in developing countries. While our initial focus for this project is on Brazil, the course will be general so as to attract a broad group of students and create a sustainable course and, as well, so that those involved (both students and faculty) can draw from a wide-array of relevant scholarship and experts in order to spark new understandings and ideas. During this time the team will finalize the draft survey instrument, which will consist of new modules that tap into cultural barriers to healthcare utilization (e.g., stigma and traditional medicines), social barriers (e.g., race-based inequalities), economic barriers (e.g., poverty), and political barriers (e.g., policy failures). We will consult regularly, by Skype or Lync, with our Brazilian partners.

May-August 2016: We will spend this time conducting a series of qualitative tests (focus groups and individual interviews) in order to adapt the instrument to the local context and validate the modules, per the LAPOP standard of testing items in-country. We will conduct a small pilot of the instrument, in order to gather proof-of-concept data to use in grant proposals. We will find ways to include undergraduate and graduate students in this process. The Littlejohn Fellowships and VU Summer Research Grants provide mechanisms for funding undergraduate involvement and collaboration over the testing of the instrument during this phase.

September-December 2016: The team will develop grant proposals aimed at attracting funds to test hypotheses generated by the data collected and to support an extensive data collection effort around this project. The multi-layered effort will include a proposal to survey the population of Rocinha, for a case study of public healthcare provision and outcomes at the site of an on-going HIV and TB treatment program, and for a national survey of Brazil in order to place this case in the broader context and to solve the “puzzle” underlying the tremendous gap in healthcare quantity (percent who access) and quality in Brazil.

(1)http://www.who.int/tobacco/research/economics/publications/oecd_dac_pov_health.pdf

(2)http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998190/