Primary Health Care Evaluation: the view of clients and professionals about the Family Health Strategy

Objective:

to evaluate the attributes of primary health care as for access; longitudinality; comprehensiveness; coordination; family counseling and community counseling in the Family Health Strategy, triangulating and comparing the views of stakeholders involved in the care process.

Method:

evaluative research with a quantitative approach and cross-sectional design. Data collected using the Primary Care Assessment Tool for interviews with 527 adult clients, 34 health professionals, and 330 parents of children up to two years old, related to 33 family health teams, in eleven municipalities. Analysis conducted in the Statistical Package for Social Sciences software, with a confidence interval of 95% and error of 0.1.

Results:

the three groups assessed the first contact access - accessibility with low scores. Professionals evaluated with a high score the other attributes. Clients assigned low score evaluations for the attributes: community counseling; family counseling; comprehensiveness - services rendered; comprehensiveness - available services.

Conclusions:

the quality of performance self-reported by the professionals of the Family Health Strategy is not perceived or valued by clients, and the actions and services may have been developed inappropriately or insufficiently to be apprehended by the experience of clients.     

Presence and extent of the primary health care attributes among children hospitalized for pneumonia

OBJECTIVE:

to analyze the presence and extent of the primary health care attributes among children hospitalized for pneumonia.

METHOD:

observational and retrospective study with hospital-based case-control design, developed in three hospitals associated to the Brazilian Unified Health System, located in a city of the State of São Paulo, Brazil. The study included 690 children under five years old, with 345 cases and 345 controls.

RESULTS:

both groups scored high for access to health services. In contrast, high scores for attributes such as longitudinality and coordination of care were observed for the controls. Despite low scores, integrality and family counseling were also high for the controls.

CONCLUSION:

knowledge of the aspects involving the primary health care attributes and its provision for child care are very important because they have the potential to support professionals and managers of the Brazilian Unified Health System in the organization of health services.     

Social determinants of health,inequality and social inclusion among people with disabilities

OBJECTIVE:

to analyze the socio-familial and community inclusion and social participation of people with disabilities, as well as their inclusion in occupations in daily life.

METHOD:

qualitative study with data collected through open interviews concerning the participants'' life histories and systematic observation. The sample was composed of ten individuals with acquired or congenital disabilities living in the region covered by a Family Health Center. The social conception of disability was the theoretical framework used. Data were analyzed according to an interpretative reconstructive approach based on Habermas'' Theory of Communicative Action.

RESULTS:

the results show that the socio-familial and community inclusion of the study participants is conditioned to the social determinants of health and present high levels of social inequality expressed by difficult access to PHC and rehabilitation services, work and income, education, culture, transportation and social participation.

CONCLUSION:

there is a need to develop community-centered care programs in cooperation with PHC services aiming to cope with poverty and improve social inclusion.     

Hospitalization of older adults due to ambulatory care sensitive conditions

OBJECTIVE

To analyze the temporal evolution of the hospitalization of older adults due to ambulatory care sensitive conditions according to their structure, magnitude and causes.

METHODS

Cross-sectional study based on data from the Hospital Information System of the Brazilian Unified Health System and from the Primary Care Information System, referring to people aged 60 to 74 years living in the state of Rio de Janeiro, Souhteastern Brazil. The proportion and rate of hospitalizations due to ambulatory care sensitive conditions were calculated, both the global rate and, according to diagnoses, the most prevalent ones. The coverage of the Family Health Strategy and the number of medical consultations attended by older adults in primary care were estimated. To analyze the indicators’ impact on hospitalizations, a linear correlation test was used.

RESULTS

We found an intense reduction in hospitalizations due to ambulatory care sensitive conditions for all causes and age groups. Heart failure, cerebrovascular diseases and chronic obstructive pulmonary diseases concentrated 50.0% of the hospitalizations. Adults older than 69 years had a higher risk of hospitalization due to one of these causes. We observed a higher risk of hospitalization among men. A negative correlation was found between the hospitalizations and the indicators of access to primary care.

CONCLUSIONS

Primary healthcare in the state of Rio de Janeiro has been significantly impacting the hospital morbidity of the older population. Studies of hospitalizations due to ambulatory care sensitive conditions can aid the identification of the main causes that are sensitive to the intervention of the health services, in order to indicate which actions are more effective to reduce hospitalizations and to increase the population’s quality of life.     

Integrality in cervical cancer care: evaluation of access

OBJECTIVE

To evaluate integrity of access to uterine cervical cancer prevention, diagnosis and treatment services.

METHODS

The tracer condition was analyzed using a mixed quantitative and qualitative approach. The quantitative approach was based on secondary data from the analysis of cytology and biopsy exams performed between 2008 and 2010 on 25 to 59 year-old women in a municipality with a large population and with the necessary technological resources. Data were obtained from the Health Information System and the Regional Cervical Cancer Information System. Statistical analysis was performed using PASW statistic 17.0 software. The qualitative approach involved semi-structured interviews with service managers, health care professionals and users. NVivo 9.0 software was used for the content analysis of the primary data.

RESULTS

Pap smear coverage was low, possible due to insufficient screening and the difficulty of making appointments in primary care. The numbers of biopsies conducted are similar to those of abnormal cytologies, reflecting easy access to the specialized services. There was higher coverage among younger women. More serious diagnoses, for both cytologies and biopsies, were more prevalent in older women.

CONCLUSIONS

Insufficient coverage of cytologies, reported by the interviewees allows us to understand access difficulties in primary care, as well as the fragility of screening strategies.     

Results of a Voter Registration Project at 2 Family Medicine Residency Clinics in the Bronx,New York

PURPOSE

Federally qualified health centers provide care to medically underserved populations, the same individuals often underrepresented in the electoral process. These centers are unique venues to access patients for voter registration services.

METHODS

We undertook a clinician-led, nonpartisan voter registration drive within 2 university-affiliated federally qualified health centers in the Bronx, New York. Patients were approached by voter registration volunteers in clinic waiting areas during a 12-week period.

RESULTS

Volunteers directly engaged with 304 patients. Of the 128 patients who were eligible and not currently registered, 114 (89%) registered to vote through this project. This number corresponded to 38% of all patients engaged. Sixty-five percent of new registrants were aged younger than 40 years.

CONCLUSIONS

This project was successful in registering clinic patients to vote. Clinics are not only health centers, but also powerful vehicles for bringing a voice to civically disenfranchised communities.     

Development and Implementation of a Clinical and Business Intelligence System for the Florida Health Data Warehouse

Objective

To develop and implement a Clinical and Business Intelligence (CBI) system for the Florida Health Data Warehouse (FHDW) in order to bridge the gap between Florida’s healthcare stakeholders and the health data archived in FHWD.

Materials and Methods

A gap analysis study has been conducted to evaluate the technological divide between the relevant users and FHWD health data, which is maintained by the Broward Regional Health Planning Council (BRHPC). The study revealed a gap between the health care data and the decision makers that utilize the FHDW data. To bridge the gap, a CBI system was proposed, developed and implemented by BRHPC as a viable solution to address this issue, using the System Development Life Cycle methodology.

Results

The CBI system was successfully implemented and yielded a number of positive outcomes. In addition to significantly shortening the time required to analyze the health data for decision-making processes, the solution also provided end-users with the ability to automatically track public health parameters.

Discussion

A large amount of data is collected and stored by various health care organizations at the local, state, and national levels. If utilized properly, such data can go a long way in optimizing health care services. CBI systems provide health care organizations with valuable insights for improving patient care, tracking trends for medical research, and for controlling costs.

Conclusion

The CBI system has been found quite effective in bridging the gap between Florida’s healthcare stake holders and FHDW health data. Consequently, the solution has improved in the planning and coordination of health care services for the state of Florida.     

Conjugal violence in the perspective of "Family Health Strategy" professionals: a public health problem and the need to provide care for the women

Objective

to construct a theoretical matrix based on the meanings of the interactions and actions experienced by the professionals regarding the nursing care practices and the health of women in situations of conjugal violence in the ambit of the Family Health Strategy.

Methods

research based in Grounded Theory. Following approval by the Research Ethics Committee, 52 professionals were interviewed in Santa Catarina, Brazil. The analysis was based on open, axial and selective codifications.

Results

the theoretical model was delimited based on the phenomenon "Recognizing conjugal violence as a public health problem, and the need for management of the care for the woman", which reflects the experience of the professionals in relation to care for the woman, as well as the meanings attributed to this care.

Conclusions

the phenomenon allows one to understand the movement of action and interaction regarding the care for the woman in a situation of conjugal violence.     

Availability of essential health services in post-conflict Liberia

Objective

To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war.

Methods

We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness.

Findings

Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county’s 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively.

Conclusion

Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.     

Prenatal Care for Adolescents and attributes of Primary Health Care

Objective

evaluate prenatal care for adolescents in health units, in accordance with the attributes of Primary Health Care (PHC) guidelines.

Method

quantitative study conducted with health professionals, using the Primary Care Assessment Tool-Brazil to assess the presence and extent of PHC attributes.

Results

for all the participating units, the attribute Access scored ≤6.6; the attributes Longitudinality, Coordination (integration of care), Coordination (information systems) and Integrality scored ≥6.6, and the Essential Score ≤6.6. Comparing basic units with family health units, the attribute scores were equally distributed; Accessibility scored ≤6.6, the others attributes scored ≥6.6; however, in the basic units, the Essential Score was ≤6.6 and, in the family health units, ≥6.6.

Conclusion

expanding the coverage of family health units and the training of professionals can be considered strategies to qualify health care.     

Tuberculosis diagnosis: primary health care or emergency medical services?

OBJECTIVE

To assess primary health care and emergency medical services performance for tuberculosis diagnosis.

METHODS

Cross-sectional study were conducted with 90 health professionals from primary health care and 68 from emergency medical services, in Ribeirao Preto, SP, Southeastern Brazil, in 2009. A structured questionnaire based on an instrument of tuberculosis care assessment was used. The association between health service and the variables of structure and process for tuberculosis diagnosis was assessed by Chi-square test, Fisher''s exact test (both with 5% of statistical significance) and multiple correspondence analysis.

RESULTS

Primary health care was associated with the adequate provision of inputs and human resources, as well as with the sputum test request. Emergencial medical services were associated with the availability of X-ray equipment, work overload, human resources turnover, insufficient availability of health professionals, unavailability of sputum collection pots and do not request sputum test. In both services, tuberculosis diagnosis remained as a physician''s responsibility.

CONCLUSIONS

Emergencial medical services presented weaknesses in its structure to identify tuberculosis suspects. Gaps on the process were identified in both primary health care and emergencial medical services. This situation highlights the need for qualification of health services that are the main gateway to health system to meet sector reforms that prioritize the timely diagnosis of tuberculosis and its control.     

"The group facilitates everything": meanings patients with type 2 diabetes mellitus assigned to health education groups

OBJECTIVE:

to interpret the meanings patients with type 2 diabetes mellitus assign to health education groups.

METHOD:

ethnographic study conducted with Hyperdia groups of a healthcare unit with 26 informants, with type 2 diabetes mellitus, and having participated in the groups for at least three years. Participant observation, social characterization, discussion groups and semi-structured interviews were used to collect data. Data were analyzed through the thematic coding technique.

RESULTS:

four thematic categories emerged: ease of access to the service and healthcare workers; guidance on diabetes; participation in groups and the experience of diabetes; and sharing knowledge and experiences. The most relevant aspect of this study is the social use the informants in relation to the Hyperdia groups under study.

CONCLUSION:

the studied groups are agents producing senses and meanings concerning the process of becoming ill and the means of social navigation within the official health system. We expect this study to contribute to the actions of healthcare workers coordinating these groups given the observation of the cultural universe of these individuals seeking professional care in the various public health care services.     

Model for the evaluation of drug-dispensing services in primary health care

OBJECTIVE

To develop a model for evaluating the efficacy of drug-dispensing service in primary health care.

METHODS

An efficacy criterion was adopted to determine the level of achievement of the service objectives. The evaluation model was developed on the basis of a literature search and discussions with experts. The applicability test of the model was conducted in 15 primary health care units in the city of Florianópolis, state of Santa Catarina, in 2010, and data were recorded in structured and pretested questionnaires.

RESULTS

The model developed was evaluated using five dimensions of analysis for analysis. The model was suitable for evaluating service efficacy and helped to identify the critical points of each service dimension.

CONCLUSIONS

Adaptations to the data collection technique may be required to adjust for the reality and needs of each situation. The evaluation of the drug-dispensing service should promote adequate access to medications supplied through the public health system.     

How do primary health care professionals deal with pregnant women who are victims of domestic violence?

Objectives

to determine how Family Health Strategy professionals recognize and deal with domestic violence in pregnant women.

Method

qualitative study based on the Theory of Praxis Intervention in Collective Health Nursing (TIPESC). Fourteen professionals at a Basic Health Unit in the east side of Sao Paulo/Brazil were interviewed. Empirical data were categorized and discussed in thematic groups. For data analysis was used the technique of Discourse Analysis.

Results

we identified low number of reported cases of domestic violence; lack of education and training of health care professionals; failure in the identification and intervention process due to bias on their personal problems, moral attitudes and prejudice against these women. In addition, the study showed that their labor process was based entirely on the biological aspects of the women and to overcome this, they need of proper rapport between health care professionals and pregnant women to deal with of domestic violence.

Conclusion

professionals should develop skills to intervene in violence against pregnant women and also modify labor processes considering women in their totality and part of society.     

Regional governance: strategies and disputes in health region management

OBJECTIVE

To analyze the regional governance of the health systemin relation to management strategies and disputes.

METHODOLOGICAL PROCEDURES

A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.

RESULTS

The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.

CONCLUSIONS

The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.     

Federalism and health policy: the intergovernmental committees in Brazil

OBJECTIVE

To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states.

METHODS

The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low.

RESULTS

Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees’ ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast.

CONCLUSIONS

The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.