Abstract

This article aims to analyze the implementation of an Adequate and Healthy Food Promotion Program in Primary Health Care in the municipalities of Minas Gerais. Mixed Methods Research with Data Concomitant Embedded Strategy. Evaluative research from the perspective of the implementation analysis was employed in the quantitative approach. An exploratory-descriptive study was conducted using content analysis in the qualitative approach. Qualitative and quantitative data were incorporated for analysis from their imbrication. The Program Implementation Level (IL) was 92.5%, representing an adequate implementation. The methodology of the actions proposed in the program and the implementation of Continuing Education were convergent strengths that emerged from data imbrication. The need for more human resources for planning and implementing the program and the lack of a kitchen for cooking workshops were identified as challenges. The Program’s implementation was adequate and can be extended to other Brazilian municipalities to help professionals structure interventions to promote adequate and healthy food in the Primary Care work routine.

Key words:
Evaluation of Research Programs and Tools; Nutrition Programs and Policies; Health Promotion; Diet Healthy; Primary Health Care

Introduction

Inadequate nutrition is one of the main risk factors for morbidity, years lost due to disability, and mortality in several countries worldwide¹1 Global Burden of Disease. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249., emphasizing non-communicable chronic diseases (NCDs), such as Obesity, Systemic Arterial Hypertension, and Diabetes Mellitus. Improved nutrition could prevent one in five deaths globally²2 Pereira TN, Gomes FS, Carvalho CMP, Martins APB, Duran ACFL, Hassan BK, Cruz JI, Mais LA, Ferraz MA, Mialon M, Johns P, Bandeira LM. Medidas regulatórias de proteção da alimentação adequada e saudável no Brasil: uma análise de 20 anos. Cad Saude Publica 2021; 37:e00153120..

In this context, healthy eating has been gaining ground on the international agenda, public policies, and national programs³3 Castro IRR. Challenges and perspectives for the promotion of adequate and healthy food in Brazil. Cad Saude Publica 2015; 31(1):7-9.. The Promotion of Adequate and Healthy Food (PAAS) is one of the National Food and Nutrition Policy (PNAN) guidelines⁴4 Brasil. Ministério da Saúde (MS). Política nacional de alimentação e nutrição. Brasília: MS; 2013.. It includes Food and Nutrition Education (EAN) actions, food regulation, and incentives for creating environments that promote healthy eating, with intersectoral articulation induced by the health sector, transcending the PHC limits⁵5 Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, Silva AS, Carvalho MFCC, Bressan LÂ, Faller LA. Evolução das ações de nutrição na atenção primária à saúde nos 20 anos da Política Nacional de Alimentação e Nutrição do Brasil. Cad Saude Publica 2021; 37:e00152620.. In this sense, the Brazilian Population Food Guide⁶6 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014., revised in 2014, innovated by proposing a classification of foods based on their processing level and bringing approaches to food systems, commensality, and overcoming obstacles related to food to increase individual autonomy⁵5 Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, Silva AS, Carvalho MFCC, Bressan LÂ, Faller LA. Evolução das ações de nutrição na atenção primária à saúde nos 20 anos da Política Nacional de Alimentação e Nutrição do Brasil. Cad Saude Publica 2021; 37:e00152620.^,77 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016.. The first development of the Food Guide called the Instructive Methodology of Group Work for Food and Nutrition Actions in Primary Care⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016., was published in 2016 to contribute to the expanded PAAS actions in PHC.

The Adequate and Healthy Food Promotion Program (PPAAS) was developed Based on these instructions, with theoretical and practical support for developing PAAS actions in PHC⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016.

8 Marques RJR, Rezende-Alves K, Soares CS, Magalhães KA, Morelli LF, Lopes ACS. Análise do trabalho em equipe multiprofissional para ações de alimentação e nutrição na atenção básica. Trab Educ Saude 2020; 18(1):e0024172.^-99 Bicalho JMF, Guimarães EAA, Freitas PP de, Lopes MS, Menezes MC, Lopes ACS, Oliveira CL. Desenvolvendo modelos para o Programa de Promoção da Alimentação Adequada e Saudável: um estudo de avaliabilidade. Res Soc Dev 2021; 10(10):e600101019051.. The PPAAS proposes educational strategies and materials to promote dynamic, participatory, and understandable meetings for clients with different education levels. Adopting methodologies based on integrative and participatory teaching-learning models, such as active methodologies, are crucial for promoting people’s health⁹9 Bicalho JMF, Guimarães EAA, Freitas PP de, Lopes MS, Menezes MC, Lopes ACS, Oliveira CL. Desenvolvendo modelos para o Programa de Promoção da Alimentação Adequada e Saudável: um estudo de avaliabilidade. Res Soc Dev 2021; 10(10):e600101019051.^,1010 Menezes MC, Mingoti SA, Cardoso CS, Mendonça RD, Lopes ACS. Intervention based on Transtheoretical Model promotes anthropometric and nutritional improvements - A randomized controlled trial. Eat Behav 2015; 17:37-44..

Group activities with food and nutrition themes in PHC, such as those proposed by the PPAAS, can promote empowerment, autonomy, and shared responsibility of clients for healthier food choices through the support of health professionals¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883.. Furthermore, using methodologies that help organize the work process can integrate professionals and strengthen the team conducting educational activities⁸8 Marques RJR, Rezende-Alves K, Soares CS, Magalhães KA, Morelli LF, Lopes ACS. Análise do trabalho em equipe multiprofissional para ações de alimentação e nutrição na atenção básica. Trab Educ Saude 2020; 18(1):e0024172.. Food and nutrition actions with an interdisciplinary approach are indispensable in the quest to improve the population’s quality of life based on the principle of comprehensiveness¹²12 Ricardi LM, Sousa MF. Educação permanente em alimentação e nutrição na Estratégia Saúde da Família: encontros e desencontros em municípios brasileiros de grande porte. Cien Saude Colet 2015; 20(1):209-218.. Thus, the PPAAS is an innovative experience in streamlining the work process, planning and implementing educational actions that aim to improve the quality and access to actions on adequate and healthy food in PHC, encouraging changes in dietary habits, and maintaining a healthy weight. However, it is necessary to monitor its implementation to assess the reorganization of collective actions to promote adequate and healthy eating that this program may or may not achieve⁹9 Bicalho JMF, Guimarães EAA, Freitas PP de, Lopes MS, Menezes MC, Lopes ACS, Oliveira CL. Desenvolvendo modelos para o Programa de Promoção da Alimentação Adequada e Saudável: um estudo de avaliabilidade. Res Soc Dev 2021; 10(10):e600101019051..

Thus, it is essential to evaluate the implementation of the PPAAS, which began in Minas Gerais in 2017 to streamline work processes in the planning and implementation of educational actions and their results. To this end, evaluative research has gained prominence, as the knowledge raised in this type of investigation can contribute to identifying problems related to the organization and functioning of programs and support decisions aimed at their improvement and consolidation¹³13 Champagne F, Brouselle A, Hartz Z, Contandriopoulos AP, Denis JL. A Análise da Implantação. In: Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: Fiocruz; 2016. p. 217-238.. Considering this context and the importance of the PAAS for health promotion and the prevention of NCDs, this study aimed to evaluate the implementation of the PAAS in municipalities in the state of Minas Gerais.

Methods

We conducted Mixed Methods with Data Concomitant Incorporated Strategy research¹⁴14 Creswell JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5ª ed. Porto Alegre: Penso; 2021.. This strategy enables triangulating methods (evaluative research from the perspective of type 1b implementation analysis¹³13 Champagne F, Brouselle A, Hartz Z, Contandriopoulos AP, Denis JL. A Análise da Implantação. In: Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: Fiocruz; 2016. p. 217-238. and qualitative exploratory-descriptive study using content analysis¹⁴14 Creswell JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5ª ed. Porto Alegre: Penso; 2021.) and techniques (multidimensional questionnaire and semi-structured interview). Type 1b implementation analysis prioritizes reflection on program implementation, understanding the variation in its complete implementation degree or level¹³13 Champagne F, Brouselle A, Hartz Z, Contandriopoulos AP, Denis JL. A Análise da Implantação. In: Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z. Avaliação em saúde: conceitos e métodos. Rio de Janeiro: Fiocruz; 2016. p. 217-238.. The methodological aspects used in this research are summarized in Chart 1.

Incorporating qualitative data supported the quantitative information, which had more significant weight in this study. It deepened the findings about the context of the implementation of the PPAAS, giving more significant evidence to the results. Quantitative and qualitative data were analyzed separately and integrated at the interpretation level to identify convergences, differences, or combinations¹⁴14 Creswell JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5ª ed. Porto Alegre: Penso; 2021..

This study limited its scope of investigation to the structure (resources employed and their organization) and process (services or goods produced) dimensions. The structure consists of the framework of health services that supports the program’s implementation and involves physical, human, and material resources and the necessary regulation. On the other hand, the process covers all activities developed in the health service and how they are run. To this end, we included actions involving health professionals and clients, whose analysis can be from a technical or administrative viewpoint based on accepted standards¹⁶16 Donabedian A. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment. Washington, D.C.: Health Administration Press; 1980..

For a better understanding of the intervention (PPAAS), Chart 2 presents, in detail, the description of the items underpinning the program’s framework, such as the setting, the development time, and the activities performed.

The ESF and NASF-AP PHC coordinators and professionals who implemented the PPAAS in the UAPS of the municipalities involved in this study participated in the research. Selecting these participants is justified by the possibility of obtaining more detailed information about the structure and process of the program, as they were directly involved in its implementation. Data were collected in 2017 in the medium-sized municipality and 2019 in the small-sized municipality.

A structured multidimensional questionnaire with evaluative questions about the structure and process was employed for collecting data, with content validated by the Delphi technique⁹9 Bicalho JMF, Guimarães EAA, Freitas PP de, Lopes MS, Menezes MC, Lopes ACS, Oliveira CL. Desenvolvendo modelos para o Programa de Promoção da Alimentação Adequada e Saudável: um estudo de avaliabilidade. Res Soc Dev 2021; 10(10):e600101019051.. The questionnaire was sent through Google Forms® to the health professionals who implemented the PPAAS in the UAPS and who had already signed the informed consent form at the beginning of the implementation.

Data were descriptively analyzed to characterize the participants’ profiles. The median was used as a measure of position, and the interquartile range as a measure of dispersion for age and time working in public health. The criteria for the structure (physical, human, and material resources, standardization) and process (continuing education and tutoring, planning activities, performing activities, and completing instruments) were analyzed by adjusting the median against the maximum score assigned to each criterion.

Analysis and judgment matrices were used⁹9 Bicalho JMF, Guimarães EAA, Freitas PP de, Lopes MS, Menezes MC, Lopes ACS, Oliveira CL. Desenvolvendo modelos para o Programa de Promoção da Alimentação Adequada e Saudável: um estudo de avaliabilidade. Res Soc Dev 2021; 10(10):e600101019051. to classify the PPAAS implementation level (IL). The criterion, the calculation method, the parameter, the assigned value, and the cut-off point were defined to analyze whether the observed values complied with the established standards for each of the 42 evaluative questions in the analysis matrix. Eleven of these evaluative questions referred to specific material resources for each activity (Actions in the Environment and Workshops), with an assigned value of 5 points. In this article, these questions are taken as a single criterion with a maximum value of 55 points, thus making a total of 32 criteria that will be presented in the results.

The PPAAS IL scoring system was defined by researchers and experts using the consensus technique. This system has different values for each of the selected criteria, per the level of importance of each as defined in the analysis matrix. At first, the observed values were determined (Σ of criteria points), and the IL was calculated (Σ of observed criteria points/Σ of expected maximum points X 100) for each component. Subsequently, the components were added to calculate the Full IL. The scores obtained were transformed into percentages from the sum of the criteria points of each dimension, taking as reference (100%) the maximum possible expected score. The four categories for the PPAAS IL were defined according to these percentages: Adequate implementation (AI: 80.0 to 100%); Partially adequate implementation (PAI: 60.0 to 79.9%); Inadequate implementation (II: 40.0 to 59.9%); Critical implementation (CI: <40.0%). Excel software was used for data processing and analysis.

We employed content analysis to analyze, deepen, and expand the findings on the PPAAS implementation context, which comprises a set of communication analysis techniques aimed at obtaining, through systematic procedures and accurate description of the content of messages (quantitative or not). These indicators allow inferring the knowledge related to the production/reception (inferred variables) conditions of the messages¹⁵15 Bardin L. Análise de conteúdo. Coimbra: Edições 70; 2016..

For this purpose, a semi-structured interview was conducted with the participants who implemented the PPAAS in the municipalities. The roadmap included questions about the facilitating and hindering factors and necessary adaptations for implementing the PPAAS. Eighteen health professionals and two PHC coordinators were interviewed. The respondents were informed about the objectives and methods adopted in the research and signed an informed consent term after clarification of their doubts.

The interviews were individual, recorded, held in a private place, and later transcribed for analysis, which consisted of three stages: pre-analysis, material exploration, and treatment of results and interpretation¹⁵15 Bardin L. Análise de conteúdo. Coimbra: Edições 70; 2016.^,1717 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo: Hucitec; 2014..

The respondents were identified by codes per the position followed by the number: Community Health Workers (ACS); Social Workers (AS); PHC coordinators (CA); Nurses (ENF); Speech therapists (FON); Nutritionists (NUT); Psychologists (PSI); Occupational Therapists (TO).

Data were incorporated to present the combined qualitative and quantitative data analysis¹⁴14 Creswell JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5ª ed. Porto Alegre: Penso; 2021. at the end of the quantitative and qualitative data analysis.

The Human Research Ethics Committee approved this work under Opinion CAAE 56698716.2.0000.5149.

Results

All participants (n=20) were women, with a median age of 37 years (IQ: 29.5-41.5) and a median time working in public health of 5.5 years (IQ: 1.0-11.5). As for the position, 25% of the participants were Community Health Workers, 20% were nutritionists, 15% were nurses, 10% were PHC coordinators, 10% were occupational therapists, 10% were psychologists, 5% were speech therapists, and 5% social workers. Approximately 33.3% of the participants completed high school, 33.3% graduated, 16.7% had a specialization, and 16.7% achieved a master’s degree.

The PPAAS IL was 92.5% (adequate implementation), and the process was the best-evaluated dimension compared to structure, with an IL of 93.1% against 91.9%.

All components were adequate in the structure dimension, except for Human Resources (HR), which was assessed as partially adequate. The components classified as partially adequate included the availability of a kitchen to hold a cooking workshop and the provision of materials by the Municipal Health Secretariat (Table 1).

Continuing Education and Tutoring and Completion of Instruments components were the best evaluated in the Process dimension, followed by Implementation of Activities and Planning of Activities, which were adequate. In the Planning of Activities component, the criteria Reading the materials in advance by the team and the coordinator obtained an inadequate evaluation. In the Implementation of the activities component, the Developed activities criterion was assessed as partially adequate (Figure 1).

Figure 2 shows the intertwining of the results obtained in the quantitative and qualitative approaches used in the evaluation to identify convergent and divergent aspects and the specificities of the PPAAS implementation.

Regarding the qualitative analysis, some PPAAS facilitating points were highlighted, converging with the quantitative results of the evaluation, such as conducting continuing education with the professionals participating in the implementation of the Program and the quality of the information contained in the Instructions⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016. that underpinned the PPAAS. The respondents highlighted that the proposed workshops are detailed, with step-by-step instructions for all the steps for their preparation and implementation, from the necessary materials, duration, and suggestions of professionals.

The respondents also highlighted the variety of themes and methods of the workshops, which makes the meetings interesting for the clients, converging the quantitative approach. Regarding Instructions⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016. and its methodology, the participants reported:

The respondents also pointed out that the information in the book Demystifying Doubts about Food and Nutrition¹⁸18 Brasil. Ministério da Saúde (MS). Desmistificando Dúvidas sobre Alimentação e Nutrição - Material de Apoio para Profissionais de Saúde. Brasília: MS; 2016. clarified misconceptions about healthy eating based on scientific evidence. The book Na Cozinha com as Frutas, Legumes e Verduras¹⁹19 Brasil. Ministério da Saúde (MS). Na cozinha com frutas, legumes e verduras. Brasília: MS; 2016. (“In the kitchen with fruits, legumes, and vegetables”) was highlighted for containing culinary recipes with affordable and tasty ingredients, as can be seen in the ACS statement:

Regarding continuing education, a respondent highlights:

The participation and interaction of clients in PPAAS actions were also identified as a positive point of the Program:

The respondents also highlighted the integration of the PHC team with the clients and the team’s involvement in assembling the panels in the dissemination and active search for clients, emphasizing the involvement of the ACS as facilitators for the implementation of the PPAAS, as shown below:

Despite the involvement of the continuing education professionals, the HR deficiency and the non-involvement of other professionals on the team were identified as difficulties, converging with the evaluation of the PPAAS IL. We highlight the need for HR to plan and perform the activities, as the work overload led to difficulties in scheduling face-to-face meetings for planning activities. The activities were planned via WhatsApp® in some units:

The lack of involvement of other professionals, who did not participate in continuing education, also emerged in the statements:

The difficulty regarding the availability of materials by the Municipal Health Secretariat was identified as a limiting factor:

The respondents presented a strategy to solve this issue:

One respondent pointed out another critical difficulty concerning physical resources:

The declining adherence throughout the workshops was identified as a hindrance to the PPAAS implementation:

As mentioned above by TO, other respondents also reported the difficulty of clients adhering to the biomedical model culture still present in health units, valuing appointments to the detriment of collective activities. Another cause pointed out for low adherence was related to the PPAAS duration:

One respondent commented on an issue pertinent to the group methodology proposed by the PPAAS:

A PPAAS specificity highlighted by the respondents is that other professionals, not just nutritionists, can lead the workshops, which facilitates its implementation in PHC and can be conducted by different professional categories, including ACS:

We observe from the reports that some professionals drew attention to the importance of a nutritionist in some workshops to address food-specific issues.

Discussion

The implementation of the PPAAS in the PHC of the municipalities of Minas Gerais was adequate. The continuing education with the professionals involved in the implementation, using instructions with active methodologies, integrated the team and the clients and, consequently, the clients’ adherence to the Program.

One of continuing health education’s objectives is to help each professional and team acquire the ability to be their self-co-authors in reinventing professional practices. This strategy aims to transform work processes and is essential to provide spaces for critical, reflective, propositional, committed, and technically competent action¹²12 Ricardi LM, Sousa MF. Educação permanente em alimentação e nutrição na Estratégia Saúde da Família: encontros e desencontros em municípios brasileiros de grande porte. Cien Saude Colet 2015; 20(1):209-218..

The Instructions on Group Work Methodology for Food and Nutrition Actions in Primary Care⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016., in turn, was pointed out as a strength for implementing the PPAAS by proposing group active methodology-based activities didactically and objectively. Furthermore, support materials, such as the book In the Kitchen with Fruits, Legumes, and Vegetables¹⁹19 Brasil. Ministério da Saúde (MS). Na cozinha com frutas, legumes e verduras. Brasília: MS; 2016. about culinary preparations and Demystifying Doubts about Food and Nutrition¹⁸18 Brasil. Ministério da Saúde (MS). Desmistificando Dúvidas sobre Alimentação e Nutrição - Material de Apoio para Profissionais de Saúde. Brasília: MS; 2016., were resources that facilitate learning about educational work with groups, providing essential clarifications to support the planning and development of proposed group educational activities⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016.^,1111 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883..

Group methodologies are good strategies for organizing and conducting the work process and favor the integration of different professional categories, strengthening the team in interdisciplinarity and establishing collective spaces for exchanges, care, and empowerment of individuals assisted and the team⁸8 Marques RJR, Rezende-Alves K, Soares CS, Magalhães KA, Morelli LF, Lopes ACS. Análise do trabalho em equipe multiprofissional para ações de alimentação e nutrição na atenção básica. Trab Educ Saude 2020; 18(1):e0024172.. However, only one of the 11 studies on EAN actions conducted in the PHC published from 2006 to 2016 had active and debating educational approaches for developing workshops, revealing the importance and innovation of PPAAS²⁰20 França CJ, Carvalho VCHS. Estratégias de educação alimentar e nutricional na Atenção Primária à Saúde: uma revisão de literatura. Saude Debate 2017; 41(114):932-948..

Another critical point in implementing the PPAAS was team integration with the clients around the same theme. Health promotion occurs between people, but it is still necessary to improve the relationships established between health services and their clients²¹21 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:1.. PAAS is a topic that all PHC professionals must work on in an interdisciplinary way, starting from the perspective of food as an experience inherent to human beings, whether clients or health professionals¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883.. In this sense, EAN actions play a crucial role, especially for the ESF, as they draw the educational work closer to the community, expanding the field of health promotion interventions²⁰20 França CJ, Carvalho VCHS. Estratégias de educação alimentar e nutricional na Atenção Primária à Saúde: uma revisão de literatura. Saude Debate 2017; 41(114):932-948..

In this context, we underscore the importance of the PPAAS since it was created based on scientific evidence, the characteristics, and needs of PHC clients. It was innovative when adopting a debating theoretical-practical approach, whose primary references were the EAN Framework Reference Guide for Public Policies²²22 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Marco de Referência de Educação Alimentar e Nutricional para as Políticas Públicas. Brasília: MDS; 2012. and the Food Guide for the Brazilian Population⁶6 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014.. Selecting these references to build the Instructions, and consequently, the PPAAS, aimed to value the active participation of the subjects, their empowerment and autonomy, and respect their food culture¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883..

Despite the appropriate IL and its strengths, we identified some weaknesses in the implementation of PPAAS, which should be discussed to resolve or adapt to further favor the program’s implementation in other municipalities. In contrast to the professionals’ work overload, the lack of a kitchen to run the culinary workshops, the shortage of materials for the workshops, and insufficient HR for planning and implementing the PPAAS were cited as obstacles to its implementation.

Difficulties related to the dimension of the Program’s structure are faced by PHC countrywide. Most UAPS are located in adapted houses without ideal conditions for performing group activities²³23 Gama CAP, Bicalho JMF, Dupin TO, Fonseca PC, Dias MEL, Moreira MFE. Estratégia de saúde da família e adesão ao tratamento do diabetes: fatores facilitadores. Rev Baiana Saude Publica 2022; 45(1):11-35.. The historical inexistence of meeting rooms in most units can hinder developing activities with the community, articulating the planning, and evaluating practices among professionals²⁴24 Moura BLA, Cunha RC, Fonseca ACF, Aquino R, Medina MG, Vilasbôas ALQ, Xavier AL, Costa AF. Atenção primária à saúde: estrutura das unidades como componente da atenção à saúde. Rev Bras Saude Materno Infantil 2010; 10:s69-s81.. In this study, although many UAPS did not have a meeting room, activities were run even in adapted spaces in the units or territorial spaces, such as community halls or churches, for example. However, this may compromise the implementation of the PPAAS vis-à-vis the lack of kitchens to hold the culinary workshops, as pointed out in the results. Notwithstanding this, the Instructions propose the possibility of adapting to simplify the realization of these workshops, such as taking sanitized and pre-prepared foods and preparing more straightforward recipes, such as juices and salads, available in the recipe book¹⁹19 Brasil. Ministério da Saúde (MS). Na cozinha com frutas, legumes e verduras. Brasília: MS; 2016., dispensing with the need for complex utensils and equipment⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016..

Another issue identified was the need for some materials from the workshops to be obtained by the professionals since they were not made available by the Municipal Health Secretariats. The lack of funds destined for the purchase of materials for PAAS educational activities, financially burdening health professionals⁸8 Marques RJR, Rezende-Alves K, Soares CS, Magalhães KA, Morelli LF, Lopes ACS. Análise do trabalho em equipe multiprofissional para ações de alimentação e nutrição na atenção básica. Trab Educ Saude 2020; 18(1):e0024172., is an issue that must be discussed with health managers since federal funding for implementing food and nutrition actions is available, and the state and municipal spheres are responsible for securing and implementing the financial resources. This financial incentive is called Financing Food and Nutrition Actions (FAN) and aims to support the implementation of the PNAN in states and municipalities. It is passed on to all states and municipalities with more than 150,000 inhabitants. Currently, the FAN also includes municipalities with a population between 30,000 and 149,999 inhabitants, subject to budget availability from the Ministry of Health²⁵25 Brasil. Ministério da Saúde (MS). Instrutivo sobre o incentivo financeiro das ações de alimentação e nutrição (FAN). Brasília: MS; 2018..

Another critical, difficult point that emerged was the need for more HR in the PHC to plan and implement PPAAS actions adequately. Developing group activities in the PHC still comes up against barriers related to team organization in the face of the services’ demands. There are many challenges in the daily life of health services, and they even involve gathering professionals around a common goal: planning educational activities in groups to encourage participation, learning, empowerment, autonomy, and the leadership of clients to promote their health¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883.. One cannot deny the advances in Brazil in making available and qualifying sufficient, well-prepared, and better-distributed professionals. However, there is no doubt about the difficulties in responding to the growing health demands arising from NCDs²⁶26 Oliveira APC, Padilla M, Micheletti FC, Leite DF. Recursos Humanos em Saúde no Fortalecimento da Atenção Primaria em direção a Saúde Universal: Prêmio APS Forte. APS Rev 2020; 2(3):245-259.. However, competencies and abilities are needed to ensure that health professionals can adapt to the different characteristics and cultural values of the population served, such as working in multidisciplinary teams in an interprofessional fashion, sensitively and empathetically²⁷27 Dussault G, Kawar R, Castro Lopes S, Campbell J. Building the primary health care workforce of the 21st century - Background paper to the Global Conference on Primary Health Care: From Alma-Ata Towards Universal Health Coverage and the Sustainable Development Goals. Geneva: WHO; 2018..

Similar to other studies²⁸28 Carvalho-Gebran FW, Vincha KRR, Cervato-Mancuso AM. The role of educator in food and nutrition by health professionals in the context of Family Health Care. Rev Nutr 2018; 31(1):71-81.^,2929 Meurer ST, Lopes ACS, Almeida FA, Mendonça R de D, Benedetti TRB. Effectiveness of the VAMOS Strategy for Increasing Physical Activity and Healthy Dietary Habits: A Randomized Controlled Community Trial. Health Educ Behav 2019; 46(3):406-416., a weakness identified in implementing the PPAAS was a declining client adherence to the Program over time, despite the active search. PPAAS adherence was 61.9%, meaning that 38.1% of the clients who started the Program still needed to finish it. Despite this, clients reported positive changes in eating habits, with an increase in the frequency of consuming fresh or minimally processed foods and reducing the consumption of ultra-processed foods³⁰30 Lima BB. Efetividade do programa Promoção da Alimentação Adequada e Saudável (PAAS) na Atenção Primária: Ensaio comunitário controlado randomizado [dissertação]. Ouro Preto: Universidade Federal de Ouro Preto; 2021..

Declining adherence to collective health promotion actions in PHC is a challenge already identified in a previous study. The most significant difficulty in creating groups is people’s low adherence³¹31 Miranda WD, Cunha TRA, Guimarães EAA, Campos DS, Luz ZMP. Programa Nacional de Suplementação de Vitamina A: educação alimentar e nutricional no contexto da Atenção Primária à Saúde. Cad Saude Colet 2021; 29(4):509-517.. One hypothesis is the effect of the preventive culture on healthcare by clients, professionals, and managers, limiting the scope of these actions in health services³²32 Caram CDS, Mendonça RDD, Marques RJR, Brito MJM, Lopes ACS. Redução da desigualdade de acesso às ações de promoção da saúde na Atenção Primária brasileira: Programa Academia da Saúde. Demetra 2021; 16:e48519.. We emphasize that collective health promotion actions must overcome the nature of “collective appointments” and be dynamic reflection moments in which clients develop their creativity, communication, and democracy toward an adequate discussion of their experiences¹⁰10 Menezes MC, Mingoti SA, Cardoso CS, Mendonça RD, Lopes ACS. Intervention based on Transtheoretical Model promotes anthropometric and nutritional improvements - A randomized controlled trial. Eat Behav 2015; 17:37-44..

A specific and positive point concerning the PPAAS was that other professionals, not just nutritionists, can conduct their activities, which is possible due to the methodology proposed by Instructions⁷7 Brasil. Ministério da Saúde (MS). Instrutivo: Metodologias de Trabalho em Grupo para Promoção de Ações de Alimentação Adequada e Saudável na Atenção Básica. Brasília: MS; 2016. that include the details of each educational activity, acting as a guide for its development. This approach allows each professional category to contribute with its knowledge, adding more experiences and knowledge to the food topic⁸8 Marques RJR, Rezende-Alves K, Soares CS, Magalhães KA, Morelli LF, Lopes ACS. Análise do trabalho em equipe multiprofissional para ações de alimentação e nutrição na atenção básica. Trab Educ Saude 2020; 18(1):e0024172.. However, this task is still challenging due to the difficulties of developing interdisciplinary practice and defining the attributions of each health professional in collective approaches when addressing intersectoral themes but still considered as belonging to a specific professional category. In this sense, the PPAAS methodology strengthens interdisciplinary teamwork and the integration between NASF-PHC and ESF¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883. professionals.

Despite the converging results, some points diverged between the evaluative research approaches. They were well evaluated in the quantitative research but pointed out as difficulties in the qualitative research. One of these points was the interest and participation of other team professionals in PPAAS activities, which was adequately evaluated by the IL, but pointed out as a weakness by the respondents. Other health professionals, besides the nutritionist, need to get more involved in EAN actions in PHC³¹31 Miranda WD, Cunha TRA, Guimarães EAA, Campos DS, Luz ZMP. Programa Nacional de Suplementação de Vitamina A: educação alimentar e nutricional no contexto da Atenção Primária à Saúde. Cad Saude Colet 2021; 29(4):509-517.. The effectiveness of EAN groups is directly influenced by the organization of the health service, the leadership, the professionals involved, and the team’s dialogue through the recognition of the affective, social, and health needs of the clients³¹31 Miranda WD, Cunha TRA, Guimarães EAA, Campos DS, Luz ZMP. Programa Nacional de Suplementação de Vitamina A: educação alimentar e nutricional no contexto da Atenção Primária à Saúde. Cad Saude Colet 2021; 29(4):509-517.^,3333 Nogueira ALG, Munari DB, Fortuna CM, Santos LF. Pistas para potencializar grupos na Atenção Primária à Saúde. Rev Bras Enferm 2016; 69(5):964-971.. In this sense, the teams with the most significant involvement of professionals with the Program in this work were those in which the leaders, recognized in the PHC as nurses, actively implemented the PPAAS.

Another divergent issue that emerged in the qualitative approach was the extended length of the PPAAS. Some respondents pointed to the high number of proposed activities and the long duration (five months) as possible reasons for the drop in adherence. However, a study conducted on EAN PHC strategies pointed out that one of the main areas for improvement of the actions was the short duration, and most studies so far had a duration of less than or equal to five months, without continuity²⁰20 França CJ, Carvalho VCHS. Estratégias de educação alimentar e nutricional na Atenção Primária à Saúde: uma revisão de literatura. Saude Debate 2017; 41(114):932-948.. The PAAS is a process that takes time, requires maintenance and continuity, and is a challenge for health professionals¹¹11 Alves KR, Marques RJR, Magalhães KA, Lopes ACS. Proposta metodológica para desenvolvimento de grupos para promoção da alimentação adequada e saudável. Res Soc Dev 2021; 10(11):e469101119883..

As a limitation of this study, the evaluation of the Program was conducted in only two municipalities in Minas Gerais. However, scientific rigor is necessary to perform an evaluative research. Furthermore, as it is a mixed method research, which involves greater complexity, we decided to hold the study in municipalities in which all the stages planned in the PPAAS had been implemented.

On the other hand, a strength of this study was to evaluate a program that works with adequate and healthy food from a systemic perspective, based on the integration of the multiple dimensions that involve eating practices, including their social, affective, cultural, and sustainability-related meanings since food is more than nutrients³⁴34 Burlandy L, Castro IRR, Recine E, Carvalho CMP, Peres J. Reflexões sobre ideias e disputas no contexto da promoção da alimentação saudável. Cad Saude Publica 2022; 37:e00195520.. This aspect corroborates the perspective that the sociocultural, economic, and political contexts must be considered when formulating PAAS programs³⁵35 Lobczowska K, Banik A, Forberger S, Kaczmarek K, Kubiak T, Neumann-Podczaska A, Romaniuk P, Scheidmeir M, Scheller DA, Steinacker JM, Wendt J, Bekker MPM, Zeeb H, Luszczynska A; Policy Evaluation Network (PEN) Consortium. Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity. BMC Public Health 2022; 22(1):1055.. Another important strength of this research is evaluating the Program’s implementation through mixed methods research, which allows a more significant deepening by considering quantitative and qualitative approaches. Finally, we note that health assessment is gaining increased importance in PHC, also articulating with funding, denoting the need for more research in this field.

Conclusion

This evaluative research showed that the implementation of PPAAS in the municipalities of Minas Gerais was adequate and could be extended to other Brazilian municipalities, according to the interest of managers and health professionals. Furthermore, it pointed out issues related to the structure, which can be improved toward better program implementation. Thus, this research will contribute to developing and disseminating more effective collective food and nutrition activities and qualifying Brazilian PHC professionals, currently emerging issues.

Acknowledgments

We are grateful to the Universidade Federal de São João Del Rei, the Universidade Federal de Ouro Preto, and the Universidade Federal de Minas Gerais.

References

Publication Dates

History