ABSTRACT

Objective:

To analyze characteristics of the home visit (HV) in Brazil, 2012 and 2017.

Methods:

Ecological study, with panel data whose units of analysis were the Primary Health Care teams in Brazil, participants of the 1st and 3rd cycles of the Program to Improve Access and Quality of Primary Care of the Unified Health System. Descriptive, inferential and spatial analyzes (alpha=5%) were performed.

Results:

There was an increase in the proportion of teams that carried out home visits at a frequency defined based on risk and vulnerability analysis and actively searched for people with respiratory symptoms and women with delayed and altered cytopathological examination. In the heat maps, the Northeast, Southeast and South regions had a higher concentration of teams that carried out the HV and carried out an active search.

Conclusion:

The maintenance and qualification of HVs must be a priority in Brazil, since there are few countries in the world with such capillarity of health services, reaching the homes of millions of people.

Keywords:
House calls; Health services; Health evaluation; Primary health care

INTRODUCTION

The Family Health Strategy (FHS), designed in 1994 as the Family Health Program (FHP), is one of the strongest actions for consolidating Primary Health Care (PHC), with the objective of promoting, preventing, recovering, and rehabilitating users’ health, with an emphasis on family as the central nucleus of care. Among the services offered that contribute to achieving its objectives, there is House Calls (HC)¹1. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Brasília: Ministério da Saúde; 2017.^,22. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde Debate 2018; 42(spe1): 18-37. https://doi.org/10.1590/0103-11042018S102
https://doi.org/10.1590/0103-11042018S10... .

HC allows health care to be provided in a more humane and welcoming way, bringing professionals closer to the community, creating an emotional bond between the parties involved and expanding the population’s access to health actions at one of the points in their care network: the home of each family. In this way, it is possible to achieve greater care effectiveness of both individuals and their families³3. Andrade AM, Guimarães AMDN, Costa DM, Machado LC, Gois CFL. Visita domiciliar: validação de um instrumento para registro e acompanhamento dos indivíduos e das famílias. Epidemiol Serv Saúde 2014; 23(1): 165-75. https://doi.org/10.5123/S1679-49742014000100016
https://doi.org/10.5123/S1679-4974201400... . Therefore, HC are of great importance as they allow professionals to provide assistance, collect data on housing conditions, and apply measures to control communicable or parasitic diseases, contributing to health education and community empowerment⁴4. Souza HP, Oliveira WTGH, Santos JPC, Toledo JP, Ferreira IPS, Esashika SNGS, et al. Infectious and parasitic diseases in Brazil, 2010 to 2017: considerations for surveillance. Rev Panam Salud Publica 2020; 44: e10. https://doi.org/10.26633/RPSP.2020.10
https://doi.org/10.26633/RPSP.2020.10... .

In the international scenario, house calls have a similar meaning to that in Brazil, providing health care to users and family members, allowing professionals to get closer to the community. In fact, there are studies that describe specific care offered during these visits in other countries, such as in the diet of users, incentives to improve the physical and psychosocial health of the aged, and postnatal care for women who have recently given birth⁵5. Al Hadi A, Paliwoda M, Dawson J, Walker K, New K. Women’s utilisation, experiences and satisfaction with postnatal follow-up care: systematic literature review. Sultan Qaboos Univ Med J. 2022; 22(4): 455-71. https://doi.org/10.18295/squmj.10.2022.059
https://doi.org/10.18295/squmj.10.2022.0... ^,66. Ergin E, Akin B, Kocoglu-Tanyer D. Effect of home visits by nurses on the physical and psychosocial health of older adults: a systematic review and meta-analysis. Iran J Public Health 2022; 51(4): 733-45. https://doi.org/10.18502/ijph.v51i4.9234
https://doi.org/10.18502/ijph.v51i4.9234... ^,77. Janmohamed A, Sohani N, Lassi ZS, Bhutta ZA. The effects of community home visit and peer group nutrition intervention delivery platforms on nutrition outcomes in low and middle-income countries: a systematic review and meta-analysis. Nutrients 2020; 12(2): 440. https://doi.org/10.3390/nu12020440
https://doi.org/10.3390/nu12020440... .

In Brazil, there is evidence that in places where HC are carried out properly, there are higher rates of early initiation of prenatal consultations, six or more prenatal consultations, vaccinations, testing, vitamin supplementation, and guidance for pregnant women, exclusive breastfeeding until six months of the baby’s life⁸8. Sanine PR, Venancio SI, Silva FLG, Aratani N, Moita MLG, Tanaka OY. Prenatal care in high-risk pregnancies and associated factors in the city of São Paulo, Brazil. Cad Saude Publica. 2019; 35(10): e00103118. https://doi.org/10.1590/0102-311X00103118
https://doi.org/10.1590/0102-311X0010311... ^,99. Carvalho MJLN, Carvalho MF, Santos CR, Santos PTF. First postpartum home visit: a protective strategy for exclusive breastfeeding. Rev Paul Pediatr 2018; 36(1): 8. https://doi.org/10.1590/1984-0462/;2018;36;1;00001
https://doi.org/10.1590/1984-0462/;2018;... ^,1010. Mues KE, Resende JC, Santos OC, Perez LG, Ferreira JA, Leon JS. User satisfaction with the family health program in Vespasiano, Minas Gerais, Brazil. Rev Panam Salud Publica 2012; 31(6): 454-60. https://doi.org/10.1590/s1020-49892012000600002
https://doi.org/10.1590/s1020-4989201200... ^,1111. Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da “Primeira Semana de Saúde Integral.” Rev Graúcha Enferm (Online) 2016; 37(3): e59248. https://doi.org/10.1590/1983-1447.2016.03.59248
https://doi.org/10.1590/1983-1447.2016.0... , in addition to increasing user satisfaction with PHC¹⁰10. Mues KE, Resende JC, Santos OC, Perez LG, Ferreira JA, Leon JS. User satisfaction with the family health program in Vespasiano, Minas Gerais, Brazil. Rev Panam Salud Publica 2012; 31(6): 454-60. https://doi.org/10.1590/s1020-49892012000600002
https://doi.org/10.1590/s1020-4989201200... and reducing hospital admissions¹¹11. Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da “Primeira Semana de Saúde Integral.” Rev Graúcha Enferm (Online) 2016; 37(3): e59248. https://doi.org/10.1590/1983-1447.2016.03.59248
https://doi.org/10.1590/1983-1447.2016.0... ^,1212. Malvezzi E. Internações por condições sensíveis a atenção primária: revisão qualitativa da literatura científica brasileira. Saúde Redes 2018; 4(4): 119-34. https://doi.org/10.18310/2446-4813.2018v4n4p119-134
https://doi.org/10.18310/2446-4813.2018v... . The visits reduce women’s doubts, fears, and anxieties regarding prenatal care, childbirth, the postpartum period, and child care. The presence of nurses and doctors in HC reduces the prevalence of problems related to psychological distress and qualifies physical examinations of women and children¹¹11. Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da “Primeira Semana de Saúde Integral.” Rev Graúcha Enferm (Online) 2016; 37(3): e59248. https://doi.org/10.1590/1983-1447.2016.03.59248
https://doi.org/10.1590/1983-1447.2016.0... ^,1313. Solano LC, Lacerda VS, Miranda FAN, Ferreira JKA, Oliveira KKD, Leite AR. Coordenação do cuidado ao recém-nascido prematuro: desafios para a atenção primária à saúde. Reme Rev Min Enferm 2019; 23: e1168. https://doi.org/10.5935/1415-2762.20190016
https://doi.org/10.5935/1415-2762.201900... .

However, a tool capable of organizing the professionals’ work process during home visits has not yet been developed/implemented in PHC services in Brazil. Therefore, there may be different HC formats, and a protocol could support these professionals. In some teams, HC can only be carried out by the Community Health Worker (CHW), while others include more team professionals. Visits may also differ regarding the use or not of protocols that take into account the vulnerability of people in the territory, as well as the use or not of planning and monitoring tools for users¹⁴14. Santos JC, Cortez DN, Macedo MML, Reis EA, Reis IA, Torres HC. Comparação das estratégias de educação em grupo e visita domiciliar em diabetes mellitus tipo 2: ensaio clínico. Rev Latinoam Enferm 2017; 25: e2979. https://doi.org/10.1590/1518-8345.2315.2979
https://doi.org/10.1590/1518-8345.2315.2... ^,1515. Oliveira NL, Souza ECF. A visita domiciliar: lócus privilegiado das ações de educação em saúde com vistas ao cuidado integral. In: Anais II Congresso Virtual de Gestão, Educação e Promoção da Saúde; 2013; São Paulo, Brasil. São Paulo: Convibra; 2013. Disponível em: https://convibra.org/publicacao/6407/
https://convibra.org/publicacao/6407/... ^,1616. Lima M, Alves JB, Lago L, Rebouças F, Grave L. Visita domiciliar na Atenção Primária à Saúde: contribuições para a formação em Psicologia. Rev Psicol Divers e Saúde 2021; 10(3): 442-54. https://doi.org/10.17267/2317-3394rpds.v10i3.3468
https://doi.org/10.17267/2317-3394rpds.v... .

Therefore, given the lack of a quality standard for HC in Brazil, the way these visits have been carried out in the daily routine of home care services is unknown. The studies identified are restricted to some municipalities in the states, simulating controlled HC conditions in community trials, or are literature reviews, with historical analysis of home visiting practices in the context before and after the Brazilian Unified Health System (Sistema Único de Saúde - SUS)¹⁰10. Mues KE, Resende JC, Santos OC, Perez LG, Ferreira JA, Leon JS. User satisfaction with the family health program in Vespasiano, Minas Gerais, Brazil. Rev Panam Salud Publica 2012; 31(6): 454-60. https://doi.org/10.1590/s1020-49892012000600002
https://doi.org/10.1590/s1020-4989201200... ^,1111. Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da “Primeira Semana de Saúde Integral.” Rev Graúcha Enferm (Online) 2016; 37(3): e59248. https://doi.org/10.1590/1983-1447.2016.03.59248
https://doi.org/10.1590/1983-1447.2016.0... ^,1717. Santos EM, Kirschbaum DIR. A trajetória histórica da visita domiciliária no Brasil: uma revisão bibliográfica. Rev Eletrônica Enferm 2008; 10(1): 220-27.^,1818. Ribeirão Preto. Prefeitura Municipal. Secretaria Municipal da Saúde. Departamento de Atenção à Saúde das Pessoas. Guia prático de visita domiciliar PARA AS Unidades de Saúde de Ribeirão Preto [Internet]. 2021 [acessado em 18 dez. 2023] Disponível em: Disponível em: https://www.ribeiraopreto.sp.gov.br/portal/pdf/saude313202111.pdf
https://www.ribeiraopreto.sp.gov.br/port... .

The studies identified do not analyze characteristics related to HC protocols and the profile of the professionals involved, nor the use of action planning tools according to the vulnerability of users⁹9. Carvalho MJLN, Carvalho MF, Santos CR, Santos PTF. First postpartum home visit: a protective strategy for exclusive breastfeeding. Rev Paul Pediatr 2018; 36(1): 8. https://doi.org/10.1590/1984-0462/;2018;36;1;00001
https://doi.org/10.1590/1984-0462/;2018;... ^,1010. Mues KE, Resende JC, Santos OC, Perez LG, Ferreira JA, Leon JS. User satisfaction with the family health program in Vespasiano, Minas Gerais, Brazil. Rev Panam Salud Publica 2012; 31(6): 454-60. https://doi.org/10.1590/s1020-49892012000600002
https://doi.org/10.1590/s1020-4989201200... ^,1111. Silva LLB, Feliciano KVO, Oliveira LNFP, Pedrosa EN, Corrêa MSM, Souza AI. Cuidados prestados à mulher na visita domiciliar da “Primeira Semana de Saúde Integral.” Rev Graúcha Enferm (Online) 2016; 37(3): e59248. https://doi.org/10.1590/1983-1447.2016.03.59248
https://doi.org/10.1590/1983-1447.2016.0... . Therefore, this study analyzed the characteristics of HC in Brazil, in two moments: 2012 and 2017.

METHODS

This is an ecological study, with panel data and a spatio-temporal approach. The units analyzed were the Family Health and Parameterized teams (we standardized the term PHC health teams) in Brazil, participants in the 1^st and 3^rd cycles of the Program for Improving Access and Quality of Primary Care of the Unified Health System (Programa de Melhoria do Acesso e Qualidade da Atenção Básica do Sistema Único de Saúde - PMAQ-AB). For spatial analyses, data were aggregated to the level of health regions. The study was written according to STROBE recommendations¹⁹19. STROBE statement--checklist of items that should be included in reports of observational studies (STROBE initiative). Int J Public Health 2008; 53(1): 3-4. https://doi.org/10.1007/s00038-007-0239-9
https://doi.org/10.1007/s00038-007-0239-... .

The first cycle of PMAQ-AB took place in 2012, simultaneously with UBS census, in which the infrastructure, equipment, facilities, human and material resources of these units were examined. The second and third cycles of the program, carried out in 2014 and 2017, respectively, were aimed at health units and teams that joined the program²⁰20. Santos DMA, Alves CMC, Rocha TAH, Queiroz RCS, Silva NC, Thomaz EBAF. Structure and work process regarding child care in Primary Health Care in Brazil: an ecological study with data from the Program for Primary Health Care access and quality improvement 2012-2018. Epidemiol Serv Saude 2021; 30(1): e2020425. https://doi.org/10.1590/S167949742021000100012
https://doi.org/10.1590/S167949742021000... ^,2121. Russo LX, Powell-Jackson T, Barreto JOM, Borghi J, Kovacs R, Gurgel Junior GD, et al. Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009-2018. BMJ Glob Health 2021; 6(7): e005429. https://doi.org/10.1136/bmjgh-2021-005429
https://doi.org/10.1136/bmjgh-2021-00542... .

PMAQ-AB assessments were commissioned by the Ministry of Health and conducted by a consortium formed by several Brazilian universities and research centers. The fieldwork was carried out by health professionals and evaluators trained by the Ministry of Health. The evaluation instrument used was organized into six modules structured within four major aspects: organization of services; work management, health care; and user satisfaction²²22. Macinko J, Harris MJ, Rocha MG. Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ): fulfilling the potential of the world’s largest payment for performance system in primary care. J Ambul Care Manage 2017; 40(suppl 2): S4-S11. https://doi.org/10.1097/JAC.0000000000000189
https://doi.org/10.1097/JAC.000000000000... ^,2323. Cruz MJB, Santos AF, Macieira C, Abreu DMX, Machado ATGM, Andrade ELG. Avaliação da coordenação do cuidado na atenção primária à saúde: comparando o PMAQ-AB (Brasil) e referências internacionais. Cad Saúde Pública 2022; 38(2): e00088121. https://doi.org/10.1590/0102-311X00088121
https://doi.org/10.1590/0102-311X0008812... .

For this study, data from the 1^st and 3^rd cycles were considered regarding the work process of PHC health teams that could be associated with HC (module 2). The microdata were obtained from the Ministry of Health databases, available to the public electronically: http://aps.saude.gov.br/ape/pmaq. To create the maps, data from the Information System of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) were used.

From PMAQ-AB, the following variables were considered:

The possible answers were yes or no to all questions.

Some questions required adaptations to promote compatibility between the variables of both cycles. In cycle 3, a team that did not carry out HC was considered to be one that responded “does not make house calls” to the question “does the team carry out house calls at different intervals?”. In cycle 1, the questions involving active search in the territory of diabetics, hypertensive patients, and pregnant women who were absent were grouped, corresponding to the question “carrying out an active search for those who were absent or abandoning treatment” in cycle 3. The “organization of demand for house calls” was the question evaluated in the third cycle, comparing with the first through the question “does the team have a survey/mapping of registered users who need to receive care at home?”.

Descriptive and inferential statistical analyses were carried out, estimating absolute frequencies, percentages, and confidence intervals for categorical variables, as well as means and standard deviations for numerical variables.

Spatial analysis was also carried out to describe the spatial distribution of variables in the federative units for both PMAQ-AB cycles. In this analysis, spatial aggregation was performed by municipality (proportion of adequate responses per municipality) and summarized using averages. Choroplectic maps were created, whose variables were classified on a 5-level scale: 0-24.99%; 25-49.99%; 50-74.99%; 75-100%; and without information (municipalities that did not have information for the variable).

Kernel maps were created. This is a simplified method to estimate the intensity of a phenomenon in a given area using Kernel density. This way, it is possible to have an overview of the intensity of the analyzed variable in the regions of the map. The variables were also classified on a 5-level scale (very low, low, medium, high, and very high), ranging from colder to warmer colors, depending on the degree of intensity of the phenomenon²⁴24. Oliveira U, Oliveira P. Mapas de Kernel como subsídio à Gestão Ambiental: análise dos focos de calor na Bacia Hidrográfica do Rio Acaraú, Ceará, nos anos 2010 a 2015. Espaço Aberto 2017; 7(1): 87-99. https://doi.org/10.36403/espacoaberto.2017.3473
https://doi.org/10.36403/espacoaberto.20... .

The analyses were carried out using Stata^® (version 14) and QGIS^® (version 3.16.9). Absolute and relative frequencies were presented, accompanied by their respective 95% confidence intervals (95%CI). The study was approved by the Research Ethics Committee of the University Hospital of Universidade Federal do Maranhão (CEP HUUFMA), under CAAE No. 92281818.9.1001.5086.

RESULTS

There were 17,203 PHC health teams participating in the first cycle and 38,865 teams in the third. More than 98% of the teams reported carrying out HC in both cycles. There was an increase in the proportion of teams that carried out HC at a frequency defined based on risk and vulnerability analysis, from 92.9% (92.5-93.3) to 98.4% (98.2-98.5). There was also an increase in the proportion of teams that actively searched for people with respiratory symptoms, from 77.7% (77.1-78.3) to 79.9% (79.5-80.3), and women with delayed and altered cytopathological examination, from 75.7% (75.1-76.4) to 86.2% (85.8-86.5) and from 86.7% (86.1-87.2) to 96.8% (96.6-97.0), respectively (Table 1).

On the other hand, there was a reduction in the proportion of teams that actively searched for pregnant women, hypertensive patients and absentees from 96.1% (95.8-96.4) to 79.93% (79.5-80.3). Other professionals, in addition to CHWs, participated in these visits in 82.6% (82.0-83.2) of the teams in cycle 1, decreasing to 77.7% (77.3-78.1) in cycle 3 (Table 1).

Choropleth maps demonstrate an improvement in the spatial distribution of variables related to HC and active search between cycles 1 and 3 in Brazilian regions and for most federative units, suggesting progress in the performance and quality of HC (Figures 1 and 2).

Although there was a significant increase in teams that include professionals other than CHWs in HC in cycle 3 (white areas of the map), areas that remain with low percentages of this variable were identified. The Northeast region has the best performance, with practically the entire territory having at least 50% of teams with HCs performed by more than one professional (Figure 1).

Figures 3 and 4 represent the heat maps for each variable in cycles 1 and 3. In the images, it can be seen that the Northeast, Southeast, and South regions have a greater concentration of teams that carry out the action (variable) analyzed, both for cycles 1 and 3. For cycle 3, a greater concentration of teams was identified in the states of Rio Grande do Norte, Paraíba, Pernambuco, and Alagoas, as well as in the states of the Southeast and South regions of the country, carrying out the actions evaluated for HC. The other Brazilian regions had a very low concentration of teams carrying out the actions investigated (Figures 3 and 4).

DISCUSSION

The performance, frequency, and organization of HCs improved in Brazil, comparing cycles 1 and 3 of the PMAQ-AB. The active search for women with delayed or altered cytopathological examination and respiratory symptoms improved in the North, Northeast, and Central-West regions. However, the active search for pregnant women, hypertensive patients, and absentees worsened between assessments.

Visits allow health professionals to get to know the reality of users, families, and the community up close, in order to enable these professionals to identify health needs and demands, establish bonds of trust, and promote people’s active participation in the care process. Thus, this service can be highlighted as relevant for longitudinality, comprehensiveness, and coordination of care, leading to the strengthening of PHC²⁵25. Quirino TRL, Jucá AL, Rocha LP, Cruz MSS, Vieira SG. A visita domiciliar como estratégia de cuidado em saúde: reflexões a partir dos Núcleos Ampliados de Saúde da Família e Atenção Básica. Revista Sustinere 2020; 8(1): 253-73. https://doi.org/10.12957/sustinere.2020.50869
https://doi.org/10.12957/sustinere.2020.... .

Furthermore, visits must be carried out based on risk and vulnerability criteria, so that families with greater needs are visited more often. Considering that these are people in need of more intense monitoring, it is important that the frequency of visits to this public exceeds the average recommended in the National Primary Care Policy (Política Nacional de Atenção Básica - PNAB)²⁶26. Nunes CA, Aquino R, Medina MG, Vilasbôas ALQ, Pinto Júnior EP, Luz LA. Visitas domiciliares no Brasil: características da atividade basilar dos Agentes Comunitários de Saúde. Saúde Debate 2018; 42(spe2): 127-44. https://doi.org/10.1590/0103-11042018S209
https://doi.org/10.1590/0103-11042018S20... . In view of this, it is important that teams know how to carry out a family risk stratification assessment, using scales such as the Coelho Savassi Family Risk Scale²⁷27. Savassi LCM, Lage JL, Coelho FLG. Sistematização de instrumento de estratificação de risco familiar: a Escala de Risco Familiar de Coelho-Savassi. J Manag Prim Health Care 2012; 3(2): 179-85. https://doi.org/10.14295/jmphc.v3i2.155
https://doi.org/10.14295/jmphc.v3i2.155... .

Although PNAB 2017 establishes the average monthly frequency of CHW visits to be carried out in each household, it does not define the criteria to their frequency. Hence, it is worth noting possible difficulties in standardizing and prioritizing HC, whether carried out exclusively by CHWs or jointly with other team professionals²⁶26. Nunes CA, Aquino R, Medina MG, Vilasbôas ALQ, Pinto Júnior EP, Luz LA. Visitas domiciliares no Brasil: características da atividade basilar dos Agentes Comunitários de Saúde. Saúde Debate 2018; 42(spe2): 127-44. https://doi.org/10.1590/0103-11042018S209
https://doi.org/10.1590/0103-11042018S20... .

An increase in the proportion of HC was observed between cycles, however, some teams continue not to do so, especially in the South and Southeast of the country. Work overload is reported by agents as difficulty in carrying out visits²⁸28. Lopes DMQ, Lunardi Filho WD, Beck CLC, Coelho APF. Cargas de trabalho do agente comunitário de saúde: pesquisa e assistência na perspectiva convergente-assistencial. Texto Contexto Enferm 2018; 27(4): e3850017. https://doi.org/10.1590/0104-07072018003850017
https://doi.org/10.1590/0104-07072018003... , signaling the teams’ lack of clarity regarding the CHW’s main duties, displacing them to other activities that require time and make it difficult to carry out HC as recommended, or even more frequently, if necessary²⁶26. Nunes CA, Aquino R, Medina MG, Vilasbôas ALQ, Pinto Júnior EP, Luz LA. Visitas domiciliares no Brasil: características da atividade basilar dos Agentes Comunitários de Saúde. Saúde Debate 2018; 42(spe2): 127-44. https://doi.org/10.1590/0103-11042018S209
https://doi.org/10.1590/0103-11042018S20... .

This situation has also directly reflected on the perception of families and other professionals, given that users and nurses were dissatisfied with the low number of families visited by CHWs²⁹29. Costa SM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Ciênc Saúde Colet 2013; 18(7): 2147-56. https://doi.org/10.1590/S1413-81232013000700030
https://doi.org/10.1590/S1413-8123201300... . A meta-synthesis on the work of the CHWs in FHS identified articles in which the theme of “lack of sizing of the work of CHWs” was addressed, highlighting the excess of expected functions and the lack of clarity of their responsibilities³⁰30. Alonso CMC, Béguin PD, Duarte FJCM. Trabalho dos agentes comunitários de saúde na Estratégia Saúde da Família: metassíntese. Rev Saúde Pública 2018; 52: 14. https://doi.org/10.11606/S1518-8787.2018052000395
https://doi.org/10.11606/S1518-8787.2018... .

In a study carried out in the Southeast region of Brazil, Costa and collaborators showed that 33.6% of CHWs reported helping higher-level professionals in clinical environments, taking on tasks such as disinfection and sterilization of clinical instruments, which would be the responsibility of nursing technicians or assistants, or administrative functions, such as scheduling appointments and exams and checking the stock of office and medical-hospital supplies. Situations like these, in addition to diverting the focus of actions in the territory, mischaracterize the role of CHWs in the health team and make it difficult to consolidate their own professional identity²⁹29. Costa SM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Ciênc Saúde Colet 2013; 18(7): 2147-56. https://doi.org/10.1590/S1413-81232013000700030
https://doi.org/10.1590/S1413-8123201300... .

It is noticed that fewer health professionals, in addition to CHWs, are carrying out HC in Brazil. This may explain why research is increasingly addressing the issue of work overload that CHWs experience, since they work in different roles, have very broad responsibilities, and are increasingly alone during HC²⁸28. Lopes DMQ, Lunardi Filho WD, Beck CLC, Coelho APF. Cargas de trabalho do agente comunitário de saúde: pesquisa e assistência na perspectiva convergente-assistencial. Texto Contexto Enferm 2018; 27(4): e3850017. https://doi.org/10.1590/0104-07072018003850017
https://doi.org/10.1590/0104-07072018003... ^,3131. Maciel FBM, Santos HLPC, Carneiro RAS, Souza EA, Prado NMBL, Teixeira CFS. Community health workers: reflections on the health work process in Covid-19 pandemic times. Ciênc Saúde Colet 2020; 25(suppl 2): 4185-95. https://doi.org/10.1590/1413-812320202510.2.28102020
https://doi.org/10.1590/1413-81232020251... .

In addition to this aspect addressed by CHWs themselves, it is important to address the possible impacts of the review of PNAB, published in 2017, on HC. PNAB became the target of criticism due to restrictive measures that put the organization of PHC at risk³²32. Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saúde Debate 2018; 42(116): 11-24. https://doi.org/10.1590/0103-1104201811601
https://doi.org/10.1590/0103-11042018116... . One of the most prominent problematized measures was the flexibility of the presence of CHWs in the composition of FHS, which could lead to the discontinuity of actions focused on the territory, compromising access and effectiveness of health actions³³33. Melo EA, Mendonça MHM, Oliveira JR, Andrade GCL. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde Debate 2018; 42(spe 1): 38-51. https://doi.org/10.1590/0103-11042018S103
https://doi.org/10.1590/0103-11042018S10... . This could have potential long-term negative impacts on both HC and other services such as vaccinations and consultations³²32. Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saúde Debate 2018; 42(116): 11-24. https://doi.org/10.1590/0103-1104201811601
https://doi.org/10.1590/0103-11042018116... .

This study also showed that the active search for pregnant women, hypertensive patients, and absentees worsened between assessments. In the last evaluation, the states of Acre, Rondônia, and Mato Grosso presented proportions below 25%. It was also observed that the Southeast and South regions had the worst rates, when compared to the other regions of the country.

Monitoring women must be carried out in a welcoming manner and must occur since prenatal care, to promote the correct provision of care to the mother-baby binomial¹³13. Solano LC, Lacerda VS, Miranda FAN, Ferreira JKA, Oliveira KKD, Leite AR. Coordenação do cuidado ao recém-nascido prematuro: desafios para a atenção primária à saúde. Reme Rev Min Enferm 2019; 23: e1168. https://doi.org/10.5935/1415-2762.20190016
https://doi.org/10.5935/1415-2762.201900... . Actively searching for pregnant women positively influences adherence to prenatal care, which leads to a better outcome during childbirth and increases the chances of women maintaining the bond during the postpartum period. It can also reduce the occurrence of new unplanned pregnancies and adherence to better self-care and baby care practices. Therefore, this active search with very low values reveals a serious public health problem in these states.

These results may reflect a lack of structure to carry out HC, such as insufficient CHWs, problems in monitoring these conditions by PHC professionals, problems with transportation from the health unit to the home of the family to be visited, problems with acceptance of visits by the community, among other factors. Also noteworthy are the FHS’s difficulties in the continued management of families, the invasion of FHS territories, the persistent culture of referral and health responsibility centered on nurses, which can make it difficult to carry out active search³⁴34. Lima VC, Linhares MSC, Frota MVV, Mororó RM, Martins MA. Atuação dos enfermeiros da Estratégia Saúde da Família na prevenção da sífilis congênita: pesquisa de opinião em um município da região Nordeste. Cad Saúde Colet 2020; 30(3): e30030283. https://doi.org/10.1590/1414-462X202230030283
https://doi.org/10.1590/1414-462X2022300... .

In relation to improving the active search for delayed and/or altered cytopathology in Brazil, it is known that the Pap smear is a simple procedure that allows finding changes in the uterine cervix, being the most appropriate method for screening cervical cancer as a quick, painless, easy-to-perform exam, carried out at primary care level, in addition to its low cost³⁵35. Mendes CF, Feitoza CN, Silva CP. Exame de Papanicolau: uma busca ativa em relação as mulheres que não realizam o procedimento, assistidas na ESF Chapadinha. Revista Multidisciplinar 2020; 20: 268-94.. When early diagnosed, the possibility of curing cervical cancer is 100%. However, as the proportion of women who do not routinely undergo preventive examinations is still high, diagnosis is often still made at a more advanced stage of the disease³⁶36. Lopes VAS, Ribeiro JM. Fatores limitadores e facilitadores para o controle do câncer de colo de útero: uma revisão de literatura. Ciênc Saúde Coletiva 2019; 24(9): 3431-42. https://doi.org/10.1590/1413-81232018249.32592017
https://doi.org/10.1590/1413-81232018249... . Amapá stood out as a state whose indicators worsened between cycles.

According to the Ministry of Health, those most “responsible” for the high levels of cervical cancer and the non-acceptance of the Pap smear in Brazil are: lack of human resources and inputs released into the health network for prevention, diagnosis, and treatment; inadequate application of living resources; poor connection between health services in providing assistance at different levels of care; inaccuracy of standards and conduct; lack of health information for the general population; and lack of clarification necessary for planning health actions³⁵35. Mendes CF, Feitoza CN, Silva CP. Exame de Papanicolau: uma busca ativa em relação as mulheres que não realizam o procedimento, assistidas na ESF Chapadinha. Revista Multidisciplinar 2020; 20: 268-94.^,3636. Lopes VAS, Ribeiro JM. Fatores limitadores e facilitadores para o controle do câncer de colo de útero: uma revisão de literatura. Ciênc Saúde Coletiva 2019; 24(9): 3431-42. https://doi.org/10.1590/1413-81232018249.32592017
https://doi.org/10.1590/1413-81232018249... .

The active search for respiratory symptoms has improved over the years, observed when comparing cycles, and the creation of the National Tuberculosis Control Program (Programa Nacional do Controle da Tuberculose - PNCT) was one of the factors that had a positive impact on Brazilian indicators related to tuberculosis, as it aims to “horizontalize” the fight against tuberculosis, through the expansion of its activities to all SUS health services. All national plans and consensuses for tuberculosis control that followed emphasized its integration into basic care, using FHS as a way to expand access to diagnosis and treatment of tuberculosis throughout Brazil³⁷37. Gaspar LMS, Braga C, Albuquerque GDM, Silva MPN, Maruza M, Montarroyos UR, et al. Conhecimento, atitudes e práticas de agentes comunitários de saúde sobre tuberculose pulmonar em uma capital do Nordeste do Brasil. Ciênc Saúde Coletiva 2019; 24(10): 3815-24. https://doi.org/10.1590/1413812320182410.01722018
https://doi.org/10.1590/1413812320182410... .

In general, a significant increase in the number of teams that participated in the PMAQ-AB between cycles 1 and 3 was noted. In general, participants in cycle 1 were the establishments with the best organized teams. However, in the last cycle, almost all teams were evaluated, enabling a more realistic analysis of the situation experienced by CHWs in Brazil. In addition to being a strong point of this study, it also makes it possible to think that the improvement in active search indicators for women with delayed or altered cytopathology and respiratory symptoms was actually greater than what was found, showing real advances in active search.

This study used data from the external evaluation of two PMAQ-AB cycles, carried out in 2012 and 2017, therefore, prior to the COVID-19 pandemic. This can be considered a limitation of the study, given that the pandemic forced a reorganization of health systems, which caused the suspension or reorganization of HC across the country³⁸38. Savassi LCM, Reis GVL, Dias MB, Vilela LO, Ribeiro MTAM, Zachi MLR, et al. Recomendações para a Atenção Domiciliar em período de pandemia por COVID-19: recomendações conjuntas do GT Atenção Domiciliar SBMFC e da ABRASAD. Rev Bras Med Fam Comunidade 2020; 15(42): 2611. https://doi.org/10.5712/rbmfc15(42)2611
https://doi.org/10.5712/rbmfc15(42)2611... .

HC were greatly affected during the pandemic, as receiving professionals in users’ homes was no longer a recommended practice. In addition to the lack of protocols for the restructuring of PHC in the context of the pandemic as a major issue, many changes were highlighted during this period, such as the recommendation for visits to be carried out in an external environment, active search via WhatsApp or telephone, and the use of personal protective equipment (PPE) during HC³⁹39. Soares ALS, Freire AVR, Vasconcelos Filho CRM, Costa JAN, Medeiros AFC, Santos MEMA, et al. Covid-19: repercussões na saúde e no processo de trabalho dos agentes comunitários de saúde. Revista Eletrônica Acervo Saúde 2022; 15(2): e9693. https://doi.org/10.25248/reas.e9693.2022
https://doi.org/10.25248/reas.e9693.2022... ^,4040. Ramos TCS, Silva TF. O trabalho na Atenção Primária em Saúde e a pandemia por Covid-19: um relato de experiência. Res Soc Dev 2021; 10(3): e38210313396. http://dx.doi.org/10.33448/rsd-v10i3.13396
https://doi.org/10.33448/rsd-v10i3.13396... .

However, the results of this study demonstrate possibilities of regions and paths that can serve as a mirror for the reorganization of services in PHC. For example, we realized that CHWs could have been more active professionals in containing the pandemic, being a powerful option for: early identification of infected patients; possibility of monitoring the care of infected patients outside the hospital; guidance to family members on the importance of using social isolation measures, wearing a mask and vaccination; continuity of care for people with chronic illnesses⁴¹41. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2020; 368: m1182. https://doi.org/10.1136/bmj.m1182
https://doi.org/10.1136/bmj.m1182... .

Despite the advances noticed between PMAQ-AB cycles in terms of carrying out, frequency, and organization of HC, it is possible that visits are taking place in a very restricted manner, or even not being carried out in some places due to the pandemic.

One may then realize that this is, in fact, a very important tool for tackling health problems in populations. There are few countries in the world with such capillarity of health services, reaching the homes of millions of people, therefore, the maintenance and qualification of HC must be a priority, even in the face of pandemics.

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