"It sure ain't easy!": an ethnographic study of primary health care for patients with hypertension and/or diabetes in Manaus, Amazonas State, Brazil

This paper analyzes the results of an evaluative study in the city of Manaus, Amazonas State, Brazil, on primary health care for patients with hypertension and/or diabetes. The ethnographic approach used access to services and comprehensiveness of health care as core analytical categories, comparing the health practices developed by Family Health Program (FHP) units with traditional non-FHP primary care units. Access to family health care units in low-income communities is limited by the precarious surrounding urban infrastructure. The main barrier to access to primary care units is distance. The lack of a referral system between the various levels of complexity jeopardizes patients' access to tests and specialists. The care supplied by the two units is limited to patient conditions that can be treated pharmacologically, thus compromising the comprehensiveness of care. The health professionals display a limited capacity to hear problems outside the immediate focus of the program activity. The paper highlights the potential for using ethnography in evaluative research on health systems and services.     

Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil

This study analyzes perceptions of performance by primary health care facilities with and without the Family Health Program in municipalities with more than 100,000 inhabitants. Questionnaires from the Primary Care Assessment Tool developed by John Hopkins University and adapted to Brazil, contemplating eight dimensions of primary health care, were applied to users and professionals from a sample of 36 family health care facilities and 28 traditional primary care facilities. Thirty health professionals with university education, 207 with secondary education, 490 adult users, and 133 family members answered the questionnaires. The overall result did not show significant differences between perceptions of family health care facilities as compared to traditional primary health care facilities, but perceptions of health professionals were consistently more favorable than those of users. Comparing the scores for each dimension, family health care facilities always scored better (with the exception of level of access), but the difference in scores between facilities with and without the Family Health Strategy was only statistically significant for all three categories of respondents in relation to the items "family focus" and "community orientation".     

Primary health care product defined by health professionals and users

OBJECTIVE: To identify the components of the primary health care (PHC) product defined by health professionals and users in order to establish indicators for evaluation. METHODS: Qualitative methodology was used with group techniques: a nominal group (health professionals) and focus groups (users). The study was performed in PHC centers in Catalonia (Spain). There were 7 groups: a) family physicians and pediatricians; b) nurses and social workers; c) staff from admissions units and customer services; d) other medical specialists; e) users; f) managers, pharmacists, pharmacologists, and technicians. Participants responded to the question: "Which features should be evaluated in the services that should be provided by PHC?". A content analysis was performed. Textual data were broken down into units and then grouped into categories, following analogy criteria. The interpretative context of the research team was taken into account. RESULTS: Health professionals and users identified 4 dimensions of the PHC product, coinciding with its basic attributes: a) access to services; b) coordination and continuity of the PHC teams with other levels of healthcare; c) relationship between health professionals and users, and d) scientific-technical quality of the PHC teams and the portfolio of services. Equity, satisfaction and efficiency appeared as keystones in all the components of the product identified. CONCLUSION: There was broad agreement in the product definition among health professionals and users. The relationship between health professionals and patients was a key element in all groups. The four dimensions should be included in the evaluation of PHC teams.     

Community health agents: training, involvement, and practices

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, S?o 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.     

Access to continuous-use medication among adults and the elderly in South and Northeast Brazil

This study aimed to evaluate the prevalence of access to continuous-use medicines for treatment of systemic arterial hypertension, diabetes mellitus, and/or mental health problems, and the associated factors. A cross-sectional study was developed under the Project for the Expansion and Consolidation of the Family Health Program in 41 cities in South and Northeast Brazil. The sample included 4,060 adults and 4,003 elderly living in the coverage areas for primary health care clinics. Prevalence of access to continuous-use medicines was 81% in non-elderly adults and 87% in the elderly. Greater access was associated with the following factors: adults in South Brazil - older age, higher socioeconomic status, type of chronic disease, and participation in support groups in the primary health clinic area; adults in the Northeast - systemic arterial hypertension with or without diabetes mellitus; elderly in the South - more schooling; and elderly in the Northeast - older age, more schooling, non-smoking, enrollment in the primary health care clinic coverage area, and the family health care model. The results show important inequity in health, reinforcing the need for policies to expand access, mainly for lower-income population groups.     

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.     

Evaluation of the effectiveness of Primary Health Care in South and Northeast Brazil: methodological contributions

The article presents the methodology used in the Baseline Study that evaluated the effectiveness of the Family Health Strategy as compared to traditional primary health care units. The study included 41 municipalities with more than 100 thousand inhabitants each, 21 from the South and 20 from the Northeast of Brazil. As the principal dependent variable and underlying premise for sampling in the Baseline Study, the effectiveness of program activities in the primary care units was analyzed in the population within the respective coverage areas, using an epidemiological survey. The health care model in the primary care units was the principal independent variable. Its effect on program activities was controlled according to geopolitical region, metropolitan area, and population size in the municipalities. Coverage of the activities was characterized according to socioeconomic, demographic, and health-related factors. The use of comparison groups, multiple-stage samples, standardized measures, adjustment for geographic and socio-demographic characteristics, and well-defined criteria for judging the findings are contributions by the methodology employed here for designing future studies to evaluate primary health care.     

Quality of prenatal care: traditional primary care and Family Health Strategy units in a city in southern Brazil

Prenatal care in traditional primary care units (UBS) and Family Health Strategy units (ESF) was evaluated by a cross-sectional study from July 2009 to February 2010 in Santa Maria, Rio Grande do Sul State, Brazil. Seven hundred and ninety-five postpartum women who had received prenatal care in either of the two types of units were interviewed. Four quality levels were used: level 1 (Kessner index modified by Takeda); level 2, which adds clinical obstetric procedures to level 1; level 3, which adds laboratory tests to level 1; and level 4, which includes all the above parameters. Prenatal care in the Family Health Strategy was superior to that of traditional primary care at all levels, with statistically significant differences in levels 1 and 2. Pregnant women received more guidance and prenatal care was superior in the Family Health Strategy. The study favored the Family Health Strategy, but improvement is still needed in the performance of procedures and laboratory tests in order to enhance prenatal care and strengthen primary care.     

Oral health teamwork in Brazilian family healthcare strategy: an analysis of studies published between 2001 and 2008

The scope of this study was to review publications between 2001 and 2008 on the work of the Oral Health Team (OHT) in Family Health Strategy (FHS) in Brazil, seeking to establish the profile of the publications and studies that can assist in the assessment of the inclusion of oral health in the strategy. The sources were articles published in national and international journals included in the LILACS, MEDLINE and BBO databases, as well as non-indexed journals. Only those articles that addressed an assessment of the role of OHT in FHS were selected (N=20). Studies published throughout the period reveal important information, though the evaluation methodologies used in most of them do not adequately show the impact of OHT actions on the conditions and access to oral health of the population attended. Findings also indicate that the municipalities have not fully performed their oral health obligations in accordance with FHS recommendations. Furthermore, barriers and advances have been identified in the construction process in which the practices of the traditional model still dominate.     

Organization of primary health care in cities belonging to project for expansion and consolidation of the family health strategy in Mato Grosso State, Brazil

This article presents part of the results from the Baseline Study on the PROESF. The objective was to evaluate primary health care in the cities of Cuiabá, Várzea Grande, and Rondonópolis, Mato Grosso State, Brazil, based on the inter-subjectivity in human relations (among health workers, users of health services, and the public at large and within institutionalized levels of social control). A qualitative and quantitative methodology was used, including interviews with key informants; short meetings with managers; focal groups with managers; and interviews with users and health professionals from pre-selected health units. Scores were assigned to all the questions that indicated participatory processes in primary care practices in the various municipalities. Despite the geopolitical identity among the municipalities and their similar access to the same public policies, there was a significant difference in their performance of the functions pertaining to the organization of primary care and the Family Health Program, in terms of portal of entry into the system, longitudinality, comprehensiveness, and coordination. Differences were observed in the type of relations that were established (participatory versus non-participatory), corresponding to the previous difference.     

Participation by indians health agents in health services: the experience in Santa Catarina State, Brazil

This study analyzes the role and training of indian health agents as defined by the National Policy for Health Care of Indians Peoples on two Indian reservations in Santa Catarina, Brazil. The health agent's role in primary care is based on mediation between traditional health practices and biomedicine, subsumed in the concept of differentiated care. On both reservations, a large turnover of indigenous health agents and lack of adequate training were observed. The indigenous health agents expressed difficulty in understanding the reasons for their activities, role ambiguity vis-à-vis the community, and communications problems with other health professionals. Considering the national policy guidelines, this study indicates that the provision of differentiated care is precarious and that a dialogue is necessary, with actual participation by all stakeholders in the health services.     

Approach to the elderly in family health programs

This article discusses the role of the Brazilian National Policy for Senior Citizens' Health in the promotion of healthy aging, preservation and improvement of functional capacity in the elderly, disease prevention, recovery of those who fall ill, and rehabilitation of those with limited functional capacity, will the goal of ensuring that senior citizens can remain in their surroundings and independently exercise their functions in society. Care for the elderly should be based primarily on the family, with support from primary health care services, under the family health strategy, representing a link between the elderly and the health system. The article goes on to list some health problems among the elderly in which family health programs can have a major impact. The Family Health Strategy in Brazil is analyzed in relation to health care for the elderly, along with the responsibilities, skills, and attributions required by the health care team.     

Family practice residencies in community health centers--an approach to cost and access concerns.

An inadequate number of trained primary care clinicians limits access to care at Community Health Centers. If family practice residents working in these centers can provide care to patients at a cost that is comparable to the center''s hiring its own physicians, then expansion of Family Practice Residency Programs into community centers can address both cost and access concerns. A cost-benefit analysis of the Family Practice Residency Program at the Fresno, CA, community center was performed; the community center is affiliated with the University of California at San Francisco. Costs included (a) residents'' salaries, (b) supervision of the family practice residents, (c) family practice program costs for educational activities apart from supervision at the community center, and (d) administrative costs attributable to family practice residents in the community center. Benefits were based on the number of patients that residents saw in the community center. Using this approach, a cost of $7,700 per resident per year was calculated. This cost is modest compared with the cost of training residents in inpatient settings. The added costs attributable to training residents in community health centers can be shared with agencies that are concerned with medical education, providing physicians to underserved communities, and increasing the supply of primary care physicians. Redirecting graduate medical education funding from hospitals to selected ambulatory care training centers of excellence would facilitate placing residents in community centers. This change would have the dual advantage of addressing the current imbalance between training in ambulatory care and hospital sites and increasing the capacity of community health centers to meet the health care needs of underserved populations.     

Family health program as a strategy of primary attention: a reality at Juazeiro do Norte

This study analyzes the practices and organization of Family Health Program, in the municipality of Juazeiro do Norte according to the discussion of elements that feature the primary attention, as proposed by Starfield. The theoretical context chosen understands the primary attention as a level of attention organized by the features: First contact, longitude, integrality, coordination. This is a qualitative research, using focus group techniques, semi-structured interview and non-participant observation in eight family health units in the municipality. There are difficulties in accessing the primary care in the units, caused by structural barriers imposed to the organization of attention, represented by an excess of clients for each team and reduced availability of medical professional. Considering that there are a compulsory enrollment of the population to the Family Health Care program health units, this level of attention in the city presents itself as a traditional doctor-hegemonic model of healing practices associated with the prioritization of vertical programs of the Ministry of Health.     

Matrixing support as an instrument of primary healthcare in mental health: multiple views and devices for resolution

The scope of this paper is to analyze the articulation of the mental health services between the teams of the Family Health Strategy and Psychosocial Care Center by the matrixing process with emphasis on comprehensive care and case resolution. The subjects included 32 users and 22 family members attended in the matrixing in mental health, 46 health professionals from the Family Health Strategy and 15 from the Psychosocial Care Centers in two cities in the state of Ceara. It is a study of a qualitative nature based on critical hermeneutics. As dictated by the results, the integration of mental health services in Primary Healthcare establishes innovative approaches for shared psychosocial care between staff, family members and users. The matrixing activities in mental health ensure broadened access and diversification of healthcare to achieve comprehensive care. Case resolution is defined by the acknowledgement of the social conditions of demand by the teams and overcoming medication-based health practices.     

An assessment of the Family Health Program in municipalities of Northeast Brazil: old and new challenges

This article presents part of the results from the Baseline Studies, an evaluative research conducted in 21 municipalities with more than 100,000 inhabitants each, in three States of Northeast Brazil. The overall objective was to assess experiences in the implementation of the Family Health Program (FHP), with a focus on inductions in the PROESF. An implementation analysis was performed, using the case study method. The analysis focused on these dimensions: political-institutional, health organization, and comprehensive care. Outstanding advances included: prioritize the FHP in high-risk areas; institutional learning, with qualification of managers and teams; definition of institutional levels for regulating the FHP; and health team-user bonds and positive perceptions concerning the program. Challenges included: strengthening of local policy and decision-making capacity; allocation of primary care resources; greater employment security for human resources; effective implementation of the health care network; strengthening of social participation; upgrading of monitoring and evaluation for decision-making; receptivity; waiting lines for tests, appointments, and hospital admissions; implementation of teamwork; health promotion and inter-sector activities.     

Social participation in health services: concepts of users and community leaders in two municipalities of Northeastern Brazil

Social participation in management of the health care system at different levels of government is one of the key policies promoted by the Unified National Health System (SUS) in Brazil. As with any new policy, success hinges on several factors such as stakeholders' interests and opinions, which have not always been considered in the past. This paper analyzes the underlying concepts of two groups of stakeholders with respect to social participation in health and the potential influence of these concepts on the effectiveness of policy implementation. A case study of two municipalities in Northeast Brazil was conducted using a combination of qualitative and quantitative social science research methods. Health services users and community leaders were interviewed. Various concepts were found in which the participatory approach to health policies was only partially reflected. Likely influences on stakeholders' concepts of social participation in health are the evolution of the broader Brazilian social context and the traditional performance of health services. Particular attention should be paid to stakeholders' opinions and concepts if policy effectiveness is to be improved.     

Mental health care in the Family Health Program: consensus and dissent in practices and principles under the psychiatric reform and health reform in Brazil

In many psychiatric reforms based on the principles of deinstitutionalization of psychiatric patients and the consolidation of territorial systems for mental health care, the emphasis is on a mental health care system that includes the primary care network. In Brazil, the Psychiatric Reform emerged within the country's overall Health Reform, with which it shares common principles for reorienting the model of care. The current article discusses the links between these two movements through actual mental health care practices within the Family Health Program (FHP), based on an ethnographic study with four family health teams, in which the authors prioritize health workers' narratives. The article analyzes these practices, the discrepancies between guidelines and practice, obstacles and advances in the operationalization of activities, and limits to the comparison and potentialities for cross-cutting application of particular epistemological fields like expanded clinical mental health practice and the FHP. The discussion is based on such concepts as the psychosocial care model, comprehensive care, social participation, territoriality, and collective actions.