Challenges and lessons from a primary care intervention in a Brazilian municipality

ABSTRACT OBJECTIVE To address the implementation of the Lab for Innovation in Chronic Conditions in Santo Antonio do Monte, indicating the main challenges and lessons of a new chronic condition model. METHODS This is an observational study based on two sources of data: 1) two cross-sectional household surveys, 2013 (2012 as reference year) and 2015 (2014 as reference year), representative for the entire population and four target groups (pregnant women; children under two years old; individuals with hypertension and diabetes); medical records of individuals who self-reported having hypertension or diabetes in the household survey of 2013. A descriptive statistics analysis was performed. RESULTS The main findings showed that the public health system is the main provider of health services, mainly primary care, in Santo Antonio do Monte. Besides, the implementation of Lab for Innovation in Chronic Conditions showed the importance of building a Primary Health Care network in small municipalities. CONCLUSIONS Community health agents and health managers played a fundamental role in the Primary Health Care network. The case study of Santo Antonio do Monte poses some challenges and lessons that clarify future interventions on building a Primary Health Care network that is essential to provide an adequate and longitudinal care to chronic conditions.

Principios orientadores del Modelo Integral de Salud Familiar y Comunitario desde la perspectiva de los usuarios / Perception of users about an Integral Model of Family and Community Health care in Santiago, Chile

Background: The integral Model of Family and Community Health care is based on three essential principles: patient centered care, comprehensive care and continuity of care. Aim: To know the perception of primary care clinic users about the elements that should be considered in a patient centered integrated health care. Material and Methods: Ten males and 31 females aged 18 to 78 years, users of two public family primary care centers participated in focus groups, which were recorded. A qualitative descriptive research design based on content analysis according to Krippendorf was done. Results: Seven issues emerged from the description of patients’ experiences: professional-patient relationship, fragmentation of care, continued care with the same professional, promotion and prevention, availability of services and patient records. Conclusions: There are difficulties to install an integral model of family and community health care. The concerns raised by participants should be considered in order to modify the design of these models.

Prática diária dos agentes comunitários de saúde: dificuldades e limitações da assistência / Daily practice of community health agents: difficulties and limitations of care / Práctica diaria de los agentes comunitarios de salud: dificultades y limitaciones de la asistencia

O presente estudo, de natureza qualitativa, objetivou conhecer as dificuldades sentidas pelos Agentes Comunitários de Saúde (ACS) no exercício da prática diária da assistência. Os dados foram coletados por meio de entrevista semiestruturada com doze ACS de quatro Unidades Básicas de Saúde de um município do estado de São Paulo. A partir dos discursos dos sujeitos, constatou-se que a carência de ações resolutivas nos serviços de saúde, a sobrecarga do enfermeiro responsável pela equipe e a rejeição dos usuários ao atendimento são fatores que dificultam a execução das ações de saúde. Essa pesquisa enfatiza as limitações manifestadas pelos participantes e aponta a importância de exploração dessa temática, buscando estratégias capazes de possibilitar a consolidação dos princípios do SUS.

This qualitative study aimed to identify difficulties experienced by Community Health Agents (CHA) in the course of daily practice of care. Data were collected from semi-structured interviews with twelve CHA from four Basic Health Units in a city of the state of São Paulo, Brazil. From an analysis of the speech of subjects, we found that the deficiency of health services, the workload of the nurses responsible for the team and the service rejection by users make it difficult to implement the health actions. This research emphasizes the limitations expressed by the health agents, and points towards the necessity of an evolving discussion of this theme, seeking strategies that enable the consolidation of community health principles.

El presente estudio, cualitativo, objetivó conocer las dificultades sentidas por los Agentes Comunitarios de Salud (ACS) en ejercicio de la práctica diaria de la asistencia. Los datos fueron colectados por medio de entrevista semi estructurada con doce ACS de cuatro unidades básicas de salud de un municipio del estado de São Paulo, Brasil. A partir de los discursos se constató que la carencia de acciones resolutivas en los servicios de salud, existe sobrecarga en el hemisferio responsable por el equipo y el rechazo de los usuarios al atendimiento son factores que dificultan a ejecución de las acciones de la salud. Esa pesquisa afirma las limitaciones manifestadas por los participantes y apuntan la importancia de exploración de esa temática, buscando estrategias capaces de posibilitar la consolidación de los principios del SUS.

Diseño y metodología para el estudio de la utilización de servicios médicos y alternativos en un área de salud / Design and methodology for studying the use of medical and alternative services in a health area

Introducción: En la utilización de los servicios de salud convergen no solo la necesidad de atención de la población en términos de enfermedad, sino sus creencias, aspectos culturales; pero, sobre todo, el complejo contexto en que se da la prestación de servicios de salud. objetivo: exponer la metodología empleada para el estudio de la utilización de los servicios médicos y alternativos en el área de salud Marcio Manduley, del municipio de Centro Habana, para la solución de sus problemas de salud. Métodos: se elaboraron tres instrumentos a partir de la revisión documental y la experiencia de nuestros investigadores, las cuales estaban dirigidas a aquellos miembros de las familias que enfermaron en los últimos 30 días o que padecían una enfermedad crónica y que hicieron o no uso de algún servicio de salud o alternativo. Resultados: Se entrevistaron 408 núcleos familiares (1 244 personas) con un promedio de 31,4 familias (95,7 personas por encuestadoras). El 89,0 porciento de las familias fueron entrevistadas de lunes a viernes (el lunes y el martes fueron los días de mayor captación). Conclusiones: La aplicación de estos instrumentos ofrece una aproximación de cómo se utilizan los servicios de salud y alternativos por la población. Su replicación, perfeccionamiento y adecuación en otros contextos es de gran ayuda a los decisores de salud para fortalecer el trabajo en el nivel primario de atención, y así brindar un servicio de calidad a la población

Introduction: the use of health services converge not only the need for care of the population in terms of illness, but their beliefs, cultural aspects, but above all, the complex context in which the provision of health services is. Objective: to present the methodology used for studing the use of medical and alternative services in Marcio Manduley health area, municipality of Centro Habana, to solve their health problems. Methods: Three instruments were developed from the literature review and the experience of our investigators, aiming those family members who became ill in the last 30 days or suffered from a chronic illness that did or did not use any alternative or health service. Results: We interviewed 408 families (1244 people) with an average of 31.4 families (95.7 people per polling). 89.0 percent of families were interviewed on weekdays (Mondays and Tuesdays were the days of higher uptake). Conclusions: The application of these tools provides an approximation on how alternative or health services are used by the population. Replication, refinement, and adaptation to other contexts are helpful to health policy makers to strengthen the work in the primary health care level, and thus provide a quality service to the population

Avaliação da qualidade da atenção primária pelos profissionais de saúde: comparação entre diferentes tipos de serviços / Quality assessment of primary care by health professionals: a comparison of different types of services

Em Porto Alegre, Rio Grande do Sul, Brasil, a rede pública de Atenção Primária à Saúde (APS) inclui as Unidades Básicas de Saúde tradicionais (UBS), a Estratégia Saúde da Família (ESF), o Centro Saúde Escola Murialdo (CSEM) e o Serviço de Saúde Comunitária (SSC) do Grupo Hospitalar Conceição. O objetivo deste estudo é comparar a qualidade da atenção à saúde do adulto entre esses diferentes tipos de serviços. A qualidade da atenção foi medida por meio de entrevistas sobre a experiência de médicos e enfermeiros com os serviços (n = 340), utilizando-se, para isso, o Primary Care Assessment Tool. O Escore Geral de APS atribuído à ESF, ao CSEM e ao SSC foi significativamente maior do que o atribuído às UBS. O SSC apresentou também Escore Geral de APS significativamente maior do que o atribuído à ESF e ao CSEM. No modelo multivariável, ter "especialidade na área de APS" e referir "oferta de educação continuada" mostraram-se associados com a prevalência de alto Escore Geral. Dessa forma, a ampliação da cobertura da ESF e o investimento na formação profissional são estratégias para qualificar a APS no município.

In Porto Alegre, Rio Grande do Sul State, Brazil, public primary healthcare (PHC) is provided by traditional Basic Health Units (BHU), the Family Health Strategy (FHS), the Murialdo Health Center (MHC), and the Community Health Service (CHS) of Grupo Hospitalar Conceição. This study compares the quality of adult healthcare among these different types of services. Quality of care was measured by interviews focusing on the experience of physicians and nurses in the services (n = 340), using the Primary Care Assessment Tool. Overall scores for the FHS, MHC, and CHS were significantly higher than for the BHU. The CHS also showed a significantly higher overall score compared to the FHS and MHC. In the multivariate analysis, the variables "specialized training in PHC" and "continuing education" were associated with high overall score. Thus, expansion of FHS coverage and investment in professional training are important potential strategies for improving PHC in Porto Alegre.

Evaluación de la efectividad de programas de visitas domiciliarias para madres adolescentes y sus hijos/as / Effectiveness of a home visit program for adolescent mothers and their children

Background: Home visiting is effective for the promotion and prevention of mother-child health in other countries, especially in vulnerable populations such as pregnant teenagers. Aim: To evalúate the association between receiving a home visiting program duringpregnancy and child development during thefirstyear oflife, maternal mental health, perception of social support and school attendance. Material and Methods: Cross sectional assessment of 132 teenage mother-sibling pairs. Ofthese, 87 received home visits and 45 were randomly assigned to a control group. The assessed variables were maternal mental health, perception of social support, Ufe satisfaction, incorporation of mothers to school after delivery, child development and frequency of child abuse and neglect. Results: Mothers that received home visits had a better mental health and went back to school in a higherproportion. No significant differences between groups were observed on perception of social support or child development. Conclusions: These results suggest the effectiveness of domiciliary visits performed by non-professionals, to improve mental health and social integration of teenage mothers.

Agentes comunitários de saúde: perfil e formação / Community health agents: profile and education

A pesquisa discute o perfil e a formação dos agentes comunitários de saúde. Não existe ainda clareza sobre o tipo de profissional necessário e a formação adequada para o desempenho da função. Trata-se de um estudo de caso com metodologia exploratória e abordagem qualitativa. A coleta de dados foi com grupo focal formado por dez agentes, selecionados intencionalmente entre aqueles com mais tempo de serviço nas Equipes da Estratégia Saúde da Família do município de Santa Maria (RS). As discussões foram gravadas e transcritas. Os dados foram trabalhados através da análise de conteúdo. Os resultados apontaram para algumas questões centrais sobre a identidade dos agentes: integração na equipe de saúde, inserção na comunidade, perfil e formação. O perfil que emerge da pesquisa não é diferente daquele proposto pelo Ministério da Saúde. No entanto, o diferencial é a busca por profissionalização, iniciativa assumida pelo próprio agente, efetivada e pautada pela realidade que ele enfrenta a partir da sua atuação. As lacunas percebidas na sua formação levam o agente a construir sua própria identidade profissional, pautada mais pelo aspecto técnico do conhecimento científico do que pela sua competência social como agente comunitário.

This research discusses the profile and education of the community health agents. There is no clarity about the kind of professional needed and the appropriate training to the fulfillment of the function. The research is a case study with exploratory methodology and qualitative approach. The data was collected with a focused group, formed by ten agents, intentional selected from those with more time in service in Family Health Strategy teams from the municipality of Santa Maria, Rio Grande do Sul State. The discussions were recorded and transcribed by the researcher. The data was interpreted by content analysis. The results pointed to some important questions concerning the identity of the community health agents: integration on the health team, insertion in the community, profile and education. The profile which emerges from the research, is not different from the one proposed by the Ministry of Health. However, the difference is the professionalization, an initiative assumed by the agent, guided by reality, which he faces in his activity. The gaps, perceived in his formation, cause the agent to construct his professional identity, determined more by the technical aspect of the scientific knowledge than by his social competence as a community agent.

Manual de práticas de atenção básica: saúde ampliada e compartilhada / Handbook of primary care practices: shared and expanded health

Manual de práticas de atenção básica: saúde ampliada e compartilhada é uma obra coletiva, desenvolvida em um movimento simultâneo e sinérgico com um processo de formação de pessoas que trabalham na atenção básica de diversos lugares do país. Tão diversos quanto podem ser Campinas e Fortaleza, por exemplo. Diversidades que são culturais, mas também de conformação da rede de serviços do SUS, de suas histórias e de seus operadores.Trata-se, portanto, de um trabalho de reflexão e ação sobre os processos de formação de pessoas para a atenção básica. Mas é também um trabalho de ação sobre a reflexão, pois esses tipos de cursos, trazendo à tona vivências e realidades dos trabalhadores, fazem da academia uma coisa viva e não um mausoléu. É nesse contato vital e pulsante, é no refletir com os trabalhadores sobre o seu dia-a-dia que nosso pensamento é fertilizado. Obra coletiva, então, de todos os que assinam o livro, mas alimentada também por outros coletivos - os que carregam com seus afazeres a manutenção da atenção básica em movimento.

[Self assessment results based on INQA model in central hospital of lOCo.]

Attention to community health and its improvement is very important. Managers of health organizations should use latest technology and knowledge tools for improvement of their services. Performance assessment is one of the most important tools for measuring the achievement of organizations to the quality improvement and better performance. There are various models for performance assessment and quality improvement in organizations. One of the most comprehensive models in named INQA has been applied in this study. This study was performed in central hospital of IOC0 based on INQA model with self assessment as its main goal. This is a descriptive and applicable case report performed in 1385. INQA standard questioner was used as the data gathering tool. Managers of lOCo hospital filed out the questioner and results were based on nine set of criteria of INQA. Each set of criteria has its own scores and total scores will describe hospitals situations. Calculated scores in each criteria were: Leadership 58%; Strategy 56.2%; Staff 42%; Resources and partners 55%; Processes 53.5%; Customer results 51%; Manpower results 41%; Community results 46%; Performance Key results 60.5%; Total points 552 from 1000; [55.2%]. According the total scores achieved this hospital to nominate for INQA prize if they can complete their documents and note to recommend INQA. Special consideration to staff criteria, manpower and community results are the arias can improve the hospital points. Education of manpower can provide better understanding from INQA model

O agente comunitário de saúde: formação, inserção e práticas / Community health agents: training, involvement, and practices

O objetivo desse estudo é identificar as contribuições que o curso de formação de agente comunitário de saúde oferecido pela Secretaria Municipal de Saúde de Campinas, São Paulo, Brasil nos anos de 2001 a 2003, para a avaliação que esses fazem da sua inserção no território, bem como apontar o impacto que teve na sua prática profissional. Trata-se de uma pesquisa de natureza qualitativa em saúde, sendo utilizada a técnica de grupo focal, e para a análise dos dados empíricos utilizamos a análise de conteúdo temática. A formação do agente comunitário de saúde tinha por objetivo inserir um profissional capaz de refletir e intervir sobre sua realidade. O Programa Saúde da Família - Paidéia incluiu o agente comunitário de saúde no sistema de saúde, para reordenar as ações trabalhadas nas unidades básicas de saúde e consolidar o modelo de saúde implantado. Constatamos que a formação possibilitou que o agente comunitário de saúde assumisse o papel de sujeito educativo produzindo um conhecimento emancipatório, estimulando a reflexão e a capacidade de análise crítica, incluindo a prática diária como um dos determinantes de seu aprendizado, na busca de solucionar problemas na comunidade.

The aim of this study was to identify contributions by the training course for community health agents provided by the Municipal Health Secretariat in Campinas, São Paulo State, Brazil, from 2001 to 2003, to evaluate their assessment concerning its role in the community, and to identify its impact on their professional practice. This was a qualitative health study using the focus group technique, and the empirical data were analyzed with thematic content analysis. Training of community health agents aimed to include a professional capable of reflecting on and intervening in the local reality. The Family Health Program - Paidéia included community health agents in the health system to help reorganize the activities in the primary health care units and consolidate the model. The training allowed community health agents to act as educational protagonists, producing emancipative knowledge and encouraging reflection and the capacity for critical analysis, including daily practice as a key determinant of their learning process in the search for solutions to the community's problems.

Performance of the lot quality assurance sampling method compared to surveillance for identifying inadequately-performing areas in Matlab, Bangladesh.

This paper compared the performance of the lot quality assurance sampling (LQAS) method in identifying inadequately-performing health work-areas with that of using health and demographic surveillance system (HDSS) data and examined the feasibility of applying the method by field-level programme supervisors. The study was carried out in Matlab, the field site of ICDDR,B, where a HDSS has been in place for over 30 years. The LQAS method was applied in 57 work-areas of community health workers in ICDDR,B-served areas in Matlab during July-September 2002. The performance of the LQAS method in identifying work-areas with adequate and inadequate coverage of various health services was compared with those of the HDSS. The health service-coverage indicators included coverage of DPT, measles, BCG vaccination, and contraceptive use. It was observed that the difference in the proportion of work-areas identified to be inadequately performing using the LQAS method with less than 30 respondents, and the HDSS was not statistically significant. The consistency between the LQAS method and the HDSS in identifying work-areas was greater for adequately-performing areas than inadequately-performing areas. It was also observed that the field managers could be trained to apply the LQAS method in monitoring their performance in reaching the target population.

A comunidade segura / Safe community

OBJETIVO: Analisar a efetividade de programas de prevenção de injúrias intencionais e não intencionais, em crianças e adolescentes, embasados nos princípios da comunidade segura. FONTES DE DADOS: Pesquisa eletrônica nas bases de dados MEDLINE e LILACS, correspondendo ao período de 2000 a 2005. Para prevenção de injúrias não intencionais, usaram-se os descritores: injury and prevention and community or population and intervention; para prevenção de injúrias intencionais, violence and prevention and community or population and intervention; foi tomada como limite a faixa etária de 0 a 18 anos. Critérios de inclusão: artigos originais, que estudaram a efetividade de intervenções utilizando mais de uma estratégia e abrangendo toda uma comunidade ou grupo, abordando injúrias intencionais e não intencionais, publicados em português, inglês ou espanhol. SíNTESE DOS DADOS: Foram obtidos 152 estudos como resultado. Considerando os critérios de inclusão, foram encontrados cinco artigos sobre prevenção de injúrias não intencionais, um sobre prevenção de injúrias intencionais e um artigo que aborda as duas questões. As pesquisas analisadas evidenciam benefícios para crianças e adolescentes, em diferentes proporções. CONCLUSÕES: Os programas que trabalham com o conceito de comunidade segura ainda são em número restrito. As investigações analisadas neste estudo apresentam resultados positivos. É preciso aumentar esforços para o desenvolvimento dessa base de evidência, respeitando as características locais, desenvolvendo indicadores de avaliação que permitam melhor comparação entre diferentes trabalhos.

Normas técnicas del sub-programa de ultrasonografía precoz nivel 1, y nivel 2 del período 22 a 26 semanas, para unidades de ultrasonografía comunal: actualización 2005 / Technical standars of early ultrasonography sub-program level 1, and level 2 of period 20 to 26 weeks, for communal ultrasonography units: update 2005

Como una forma de promover el desarrollo de unidades de ultrasonografía comunal en el país, hemos decidido publicar nuestras actuales Normas Técnicas, fruto de la experiencia acumulada y publicada por más de 20 años.

Situación de salud y nutrición en la población menor de 18 años de Providencia y Santa Catalina / Health and nutrition state in younger than 18 population from Providencia and Santa Catalina

Las enfermedades transmisibles de notificación obligatoria continúan teniendo una prevalencia significativa en la comunidad. Con los resultados del estudio hecho en torno a esta problemática sepretende evaluar la situación de salud y nutrición de la población infantil de las Islas de Providencia y Santa Catalina. Metodología: durante un período de seis días se realizó una brigada de salud. Se valoraron médicamente los niños entre cero y 18 años de edad. Se clasificaron los pacientes de acuerdo con las patologías más frecuentes, con los grupos etéreos, con el estado nutricional y con la afiliación a seguridad social. Resultados: se valoraron 366 pacientes, 164 niñas y 202 niños. La infección respiratoria aguda fue la tercera causa de consulta de la población menor de cuatro años de edad. La condición de malnutrición predominante fue la de sobrepeso. Más de la mitad de la población infantil pertenece al régimen subsidiado. El consumo de frutas y verduras es deficiente. Conclusión: las estrategias en salud en la población de Providencia deben estar encaminadas hacia la disminución de la prevalencia de sobrepeso y de enfermedades transmisibles dentro de la población infantil mediante programas de atención básica.

Missed opportunities for immunization in children under 2 years attending an urban teaching hospital.

A cross-sectional survey was done to assess the missed opportunity for immunization (MOI) in children under two years of age attending Medical Outpatient, Newborn Follow-up Service and Immunization Clinic of Institute of Child Health and to evaluate interventions. Baseline survey phase-I was done and two interventions: (i) education and awareness of immunization among health personnel; and (ii) attaching immunization slip to the outpatient form were done. After each intervention phase-II and phase-III surveys were carried out. The data from the different phases were analyzed for the effect of interventions. The total number of children surveyed were 634; 423 from Medical Outpatients, 108 from Newborn Follow-up Service and 103 from immunization Clinic. MOI was 35.5%, 23.1% and 9.7% in the above health facilities, respectively. After intervention I, the MOI was 24.5% and 12.2% in Medical Outpatient and Newborn Follow-up Service and none in Immunization Clinic. After intervention-II there was an improvement in immunization of 18.4%, 30.4% and 16.0% in the three health facilities mentioned above. MOI was avoided because the medical officers advised immunization in the above children. The difference in the MOI among Medical Outpatient and Immunization Clinic between baseline, phase-I and phase-II were significant (p < 0.001). It is concluded that MOI can be brought down by creating awareness periodically and that attaching an immunization schedule to the outpatient forms is an effective method of reducing MOI.

Los servicios de salud y las comunidades Indígenas / The services of health and the indigenous communities

La Tésis Servicios de Salud y Comunidades Indígenas, trata de demostrar la incogruencia que existe entre el modelo de salud oficial y la realidad indígena de nuestro país.El propósito fundamental del presente trabajo es de aportar conocimientos y estimular reflexiones sobre la situación del Indio, de modo que puedan ser utilizados en la elaboración de políticas de salud encaminadas a este sector; o en investigaciones socio-culturales de mayor profundidad.El presente trabajo se realizó en Yanahurco Grande, comunidad indígena de altura de la provincia de Cotopaxi. Se emplearon técnicas de investigación de fuente directa (documental), y directas como entrevistas, observación participante, reuniones focales y estudio de caso de una familia tipo de la comunidad