Introduction

Dengue is the arbovirus that most affects humankind and is considered to be an endemic disease in over 100 countries. It is estimated that 390,000,000 individuals are at risk of infection.⁽¹⁾ In Brazil, the growing number of severe cases and deaths makes this health condition even more significant.⁽³⁾

Between 2000 and 2010 in the state of Mato Grosso do Sul and its capital city, Campo Grande, dengue incidence followed the pattern found for the country’s Midwest region and for Brazil as a whole, involving cycles of high transmissibility. In 2010, the incidence rate for the state of Mato Grosso do Sul was 1,167.8 cases per 100,000 inhabitants, while the rate for Campo Grande city was 3,952.5 cases per 100,000 inhab.⁽⁵⁾In the years that followed, the dengue epidemics that occurred had a well-defined pattern involving cycles every three years. In 2013, when infection was at its highest, the state recorded 3,017.9 cases per 100,000 inhab., while its capital city recorded 5,605.0 cases per 100,000 inhab. In 2016, the state recorded 1,671.3 cases per 100,000 inhab. and the capital recorded 3,293.93 cases per 100,000 inhab.⁽⁶⁾

The National Dengue Control Program was created in 2002 as a strategy to address this endemic disease. One of its components was the integration of dengue control actions performed by endemic disease control workers (EDCW) with the activities of community health workers (CHW) in the Family Health Strategy teams.⁽⁸⁾ In 2009, the Ministry of Health alerted as to the need to reorganize work processes and define the roles and responsibilities of these health workers. The following year, Health Ministry Ordinance No. 1007, dated May 4^th 2010, reaffirmed EDCW integration in Primary Health Care.⁽⁹⁾

In Campo Grande, these recommendations were put into place in 2011, under the coordination of the Health Care and Health Surveillance Directorates. The reference for this process was a publication produced by the municipal government entitled ‘Instructional Booklet – EDCW/CHW Integration in the Family Health Strategy’. It established the work process and the attributions of EDCWs and CHWs working in the same territorial area.⁽¹¹⁾

The objective of this study was to describe the process of integrating endemic disease control workers – EDCW – into the Family Health Strategy, in Campo Grande city, capital of the state of Mato Grosso do Sul, Brazil, in 2017.

Methods

This was a descriptive cross-sectional study conducted between February and May 2017 at four Family Health centers in urban areas of Campo Grande, MS.

The Family Health centers were selected by convenience, taking one from each of the municipality’s four Health Districts and ensuring that their teams had sufficient length of experience with EDCW integration. Of the four Family Health centers, three were chosen because they were the first to take part in the pilot project in 2011 and the fourth took part with effect from 2012.

EDCWs at work at the time of data collection and who had worked for more than six months at the Family Health center were invited to take part in the study.

A self-administered semi-structured questionnaire was used to collect the data (included as supplementary material to this manuscript), developed based on the Health Ministry’s Instructional Booklet, containing 24 questions divided into three topics: (i) work process organization; (ii) vector control actions; (iii) job responsibilities.

The Instructional Booklet proposes use of two work tools: (i) the checklist, a specific CHW tool, used during household visits to record the main problems found when inspecting the property and serving to inform CWH instructional and educational actions with families (living in the visited household) and to notify them as to the need to eliminate uncovered water recipients and rubbish;⁽¹²⁾ and (ii) the Rapid Aedes aegypti Rate Estimator (LIRAa in Portuguese), an instrument for estimating the degree of infestation and distribution of the vector mosquito in the household environment.⁽¹³⁾

Data collection was scheduled in advance with the manager of the Family Health center according to the availability of the health workers.

Microsoft Excel^® 2010 was used to support data organization and analysis, involving tabulation of absolute and relative frequencies of CHW/EDCW use of the different work tools, their participation in team meetings, supervision of their activities and the person responsible for supervision, and the importance of integrating the two categories of health workers as perceived by them.

The study project was approved by the Federal University of Mato Grosso do Sul Research Ethics Committee: Certificate of Submission for Ethical Appraisal No. 62362716.7.0000.0021, issued on January 25^th 2017. All participants signed a Free and Informed Consent form.

Results

In all, the 12 teams working at the four Family Health centers were comprised of a total of 75 CHWs and 8 EDCWs. Eighteen 18 CHWs were considered to be losses: 5 because of annual leave and 13 because of sick leave. As such, a total of 65 health workers took part (57 CHWs and 8 EDCWs).

With regard to work tools (Table 1), when asked about what they did when items on the checklist had unsatisfactory results when inspecting properties, the majority of the CHWs (42/57) informed that they gave guidance to the property dweller and 40/57 stated that they carried out mechanical vector control at the site. Over half the CHWs (33/57) did not use the Rapid Aedes aegypti Rate Estimator for planning their actions, justifying this by stating that the results were rarely presented and discussed in team meetings, while the majority of EDCWs (7/8) stated they used it routinely. Moreover, the CHWs acknowledged that the Rapid Aedes aegypti Rate Estimator results can influence the activities they carry out, by giving visibility to places where risk is greater (21/57) and intensifying visits (15/57).

Table 2 illustrates the results with regard to work process. All 65 participants provided guidance to property dwellers about how to avoid and eliminate possible Aedes aegypti breeding sites, 62/65 gave guidance on dengue signs and symptoms and 58/65 carried out mechanical vector control. Weekly team meetings were reported by 53/65 workers. All 8 EDCWs and 54/57 CHWs stated that their dengue control activities were supervised. Of these, 30/57 CHWs reported that supervision was done by the team nurse, 2/57 CHWs and 7/8 EDCWs, by the area supervisor, and just one (1/8) EDCW and 25/57 CHWs said that supervision was shared by the nurse and the area supervisor.

Seven (7/8) EDCWs and 29/57 CHWs considered that EDCW integration into Family Health Strategy teams was very important, and that positive points of integration were (i) team work, for 7/8 EDCWs and 23/57CHWs, and (ii) prioritization of Family Health Strategy actions, highlighted by 8/57 CHWs. With regard to negative factors, lack of autonomy to perform legal interventions was predominant among 6/8 EDCWs; while among CHWs, 14/57 reported absence of intersectoral workflow, and 8/57 reported accumulation of work tasks (Table 3).

Discussion

This study described the process of EDCW integration in the Family Health Strategy, according to (i) work process organization, (ii) vector control actions and (iii) job responsibilities. All participants gave guidance to property dwellers about possible vector breeding sites and two thirds of them gave guidance about dengue signs and symptoms. The Rapid Aedes aegypti Rate Estimator was used by a minority of the CHW and by the majority of the EDCWs. EDCW integration in the Family Health Strategy was perceived as being very important for the majority of the EDCWs and for around half the CHWs.

EDCW integration in the Family Health Strategy, as determined by the Ministry of Health,⁽⁶⁾ was supported in Campo Grande by the ‘Instructional Booklet – EDCW/CHW Integration in the Family Health Strategy’, which also recommends the use of work instruments such as the checklist, this being a specific CHW tool. A similar instrument was developed in São José do Rio Preto, São Paulo, known as the ‘property record’, which enabled monitoring of the situation found at the property, by means of assessing needs for changes in the proprietor’s behavior in relation to the points raised in the previous visit.⁽¹⁴⁾

The Rapid Aedes aegypti Rate Estimator was little used by the CHWs in this study, given the low feedback on its results to the rest of the team. Socializing results is important for obtaining support in actions intended to address endemic diseases in each municipality, and also to engage support of the population and sectors other than the Health sector.⁽¹³⁾

The scope of the responsibilities recommended in the Instructional Booklet provides that the health center manager should ensure meetings and encourage EDCW participation in these discussion spaces.⁽¹⁴⁾ This study found that meetings were held weekly and that nurses, CHWs and EDCWs participated most in them. It should be noted that the Ministry of Health recommends that all health workers comprising the Family Health Strategy teams should take part.⁽¹⁵⁾

There were few reports of shared supervision in this study. Supervision by nurses of CWH actions in relation to health surveillance and supervision by the area supervisor of EDCW actions in relation to vector and zoonosis control, strengthens integrated actions within the array of Primary Care activities.⁽⁹⁾ Moreover, supervision of EDCW activities by university-qualified Family Health Strategy workers facilitates their integration as team members.⁽¹⁶⁾

Identification of factors that hinder or assist the process of EDCW integration in dengue prevention and control activities within the Family Health Strategy contributes to cooperation and coordination, as well as assisting local management in evaluating and analyzing the impacts of their actions.⁽¹⁷⁾With regard to the positive aspects, the reports regarding team work, information sharing, immediate case notification and prioritization of Family Health Strategy actions suggest the relevance of integrating EDCWs into the Family Health Strategy teams for dengue control actions. As for the negative aspects, accumulation of work tasks by CHWs and absence of intersectoral workflow in terms of effective integration as perceived by some CHWs, and absence of autonomy to carry out legal interventions as reported by both EDCWs and CHWs, can cast doubt on the work carried out by community health workers as perceived by the families under their responsibility.

Although this study did not examine the participation of other health worker categories – nurses, area supervisors, local managers etc. –, its findings can provide a basis for further studies and thus expand the discussion on integration between endemic disease control workers and community health workers.