Abstract

This article aims to evaluate the childcare appointments by health professionals working at the Family Health Strategy in municipalities in the State of Paraíba, compare the performance by health team type (The Mais Médicos Program or conventional), and analyze the association of client satisfaction with the developed actions. This cross-sectional study evaluated the structural conditions of health units, the work process of health professionals, and client satisfaction, observing childcare appointments in 22 health teams. Poor employment relationships and professionals’ knowledge about child growth curves were highlighted in the structure. In the 175 appointments observed, we detected neglect in completing the Child Health Booklet (CHB), obtaining data on food consumption, and guidance practices. Only 36% of the appointments were classified with adequate duration. There was greater satisfaction for appointments developed in health teams of the Mais Médicos Program, with longer duration and better performance in guidance practices. The implementation of childcare appointments reveals significant gaps that can influence maternal satisfaction.

Key words:
Primary Health Care; Childcare; Process Assessment (Healthcare)

Introduction

Child healthcare is essential for healthy development and one of the priority fields of care that should be provided by health professionals in the Family Health Strategy (ESF)¹1 Brígido AF, Santos EO, Prado EV. Qualificação do Cuidado a Puericultura: uma Intervenção em Serviço na Estratégia de Saúde da Família. Rev Fund Care Online 2019; 11(n. esp.):448-454.^,22 Oliveira BLCA, Moreira JPL, Luiz RR. A influência da Estratégia Saúde da Família no uso de serviços de saúde por crianças no Brasil: análise com escore de propensão dos dados da Pesquisa Nacional de Saúde. Cien Saude Colet 2019; 24(3):1495-1505.. In this context, it is vital for monitoring child health and promoting healthy growth and development. Childcare appointments should include child assessment, growth and neuropsychomotor development monitoring, prevalent childhood illnesses care, and development of primary healthcare promotion actions regarding immunization, nutrition, and accident prevention¹1 Brígido AF, Santos EO, Prado EV. Qualificação do Cuidado a Puericultura: uma Intervenção em Serviço na Estratégia de Saúde da Família. Rev Fund Care Online 2019; 11(n. esp.):448-454.^,33 Gaíva MAM, Monteschio CAC, Moreira MDS, Salge AKM. Avaliação do crescimento e desenvolvimento infantil na consulta de enfermagem. Av Enferm 2018; 36(1):9-21.. The systematic monitoring of the child’s growth and development enables the implementation of essential practices to reduce child morbimortality⁴4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19..

Despite the importance of child growth and development surveillance, evidence suggests that its implementation in Brazil needs to be stronger and influenced by factors such as low awareness and lack of preparation of health professionals, which impairs the quality of care provided to children³3 Gaíva MAM, Monteschio CAC, Moreira MDS, Salge AKM. Avaliação do crescimento e desenvolvimento infantil na consulta de enfermagem. Av Enferm 2018; 36(1):9-21.

4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19.^-55 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.. These gaps can limit advances in the health of the child population⁶6 World Health Organization (WHO). Partnership for Maternal, Newborn and Child Health. Consultation on improving measurement of the quality of maternal, newborn and childcare in health facilities. Geneva: WHO; 2013., while client satisfaction with the care received can minimize them⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.^,88 Malaquias TSM, Gaíva MAM, Higarashi IH. Percepções dos familiares de crianças sobre a consulta de puericultura na estratégia saúde da família. Rev Gaucha Enferm 2015; 36(1):62-68.. From the patient’s perspective, satisfaction stems from their interaction with health professionals, valuing their ability to improve the most crucial care attributes⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.. As an outcome indicator of health services, satisfaction allows analyzing which objectives are being achieved, reviewing professional practices, and reshaping care organization⁹9 Modes PSSA, Gaíva MAM. Satisfação das usuárias quanto à atenção prestada à criança pela rede básica de saúde. Esc Anna Nery 2013; 17(3):455-465.^,1010 Gomide MFS, Pinto IC, Bulgarelli AF, Santos ALP, Gallardo MPS. User satisfaction with primary health care: an analysis of access and care. Interface (Botucatu) 2018; 22(65):387-398..

The ESF effects and their impacts on health indicators are controversial, questionable, and poorly established. This situation is related to implementing this care model associated with socioeconomically underserved contexts and weak health services²2 Oliveira BLCA, Moreira JPL, Luiz RR. A influência da Estratégia Saúde da Família no uso de serviços de saúde por crianças no Brasil: análise com escore de propensão dos dados da Pesquisa Nacional de Saúde. Cien Saude Colet 2019; 24(3):1495-1505., which also characterizes the Mais Médicos Program (PMM)⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.^,1111 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796. design. The program is considered one of Brazil’s primary responses to the need for public investment in health to strengthen PHC and expand ESF coverage⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.^,1111 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796.. Evidence has shown positive PMM repercussions in training, the work process, the quality of care, and client satisfaction. However, it is necessary to develop research focusing on the care offered by the program’s health professionals, namely, comparing the care provided with conventional ESF teams¹¹11 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796.. This study brings a new look at the theme from the perspective of child healthcare.

The present study aimed to evaluate the childcare appointments by health professionals working in the ESF in municipalities in the State of Paraíba, Brazil, to compare the performance by health team type (PMM or conventional) and to analyze the association of client satisfaction with the actions developed.

Methods

Study design

This cross-sectional study evaluated ESF health professionals’ childcare appointments based on the health units’ structural conditions, the work process, and client satisfaction.

Context

We selected municipalities in the state of Paraíba with a population ranging from 30,000 to 149,999 inhabitants with funding incentives for structuring and implementing food and nutrition actions¹²12 Brasil. Ministério da Saúde (MS). Portaria nº 55, de 6 de janeiro de 2017. Estabelece incentivo de custeio para a estruturação e implementação de ações de alimentação e nutrição pelas Secretarias de Saúde dos municípios que possuem população entre 30.000 e 149.999 habitantes (IBGE) e do Distrito Federal, com base na Política Nacional de Alimentação e Nutrição (PNAN). Diário Oficial da União 2017; 18 jan. and actions aimed at preventing childhood obesity within the Health Program in Paraíba to participate in the School Health Program¹³13 Brasil. Ministério da Saúde (MS). Portaria nº 2.706, de 18 de outubro de 2017. Lista os Municípios que finalizaram a adesão ao Programa Saúde na Escola para o ciclo 2017/2018 e os habilita ao recebimento do teto de recursos financeiros pactuados em Termo de Compromisso e repassa recursos financeiros para Municípios prioritários para ações de prevenção da obesidade infantil com escolares. Diário Oficial da União 2017; 20 out.. We selected municipalities with full ESF coverage with Family Health Support Centers (NASF), including a nutritionist linked to at least one PMM health team or NASF without a nutritionist linked to at least a conventional health team. Meeting these criteria, the survey totaled seven of the 12 municipalities with financial incentives. One of the municipalities was excluded as it had partial ESF coverage, and another because it did not have health teams per the eligibility criteria. Moreover, three municipalities were also excluded because they were considered for other evaluations with similar characteristics.

In the municipalities chosen to participate in the survey, we selected all health teams in the urban area that still needed to change the health team type (PMM or conventional) two years before data collection. This information was obtained through the National Register of Health Establishments (http://cnes2.datasus.gov.br) or via personal contact with the nurses of the health teams. The number of PMM and conventional health teams per municipality respected their composition. The study included professionals who performed childcare appointments and children younger than two years (0-24 months) whom they assisted on the day of data collection on a typical work day. Data were collected at health facilities from May to September 2018.

Data sources

Information on the structure of the health units referred to the availability of their own office, anthropometric equipment, the Child Health Booklet (CHB), and the profile of professionals who performed the childcare appointment according to the professional relationship (type and time) and their knowledge of child growth curves. To this end, we used a standardized questionnaire with closed-ended questions answered by the professionals involved in the service. The assessment of knowledge about growth curves was based on a case scenario (hypothetical case) of a child younger than two years old, with information on head circumference, weight, and length. We requested the records and interpretation of head circumference/age, weight/age, length/age, and body mass index/age based on the corresponding growth curves available in the CHB. Knowledge was considered adequate when records and interpretation were correct.

The actions developed by health professionals were obtained by observing childcare appointments. The observation was conducted by a pair of interviewers who explained the activity’s objective in advance and remained at the end of the appointment room without expressing any opinion or behavior. A specific form was used to record the procedures adopted, with “yes” and “no” answers. The practices of interest were measuring growth and assessing development; guidance on growth and development; records of growth and development in the CHB (completion of growth curves and development milestones); monitoring of growth and development through the CHB (continuous completion of growth curves and development milestones); assessment of food consumption and counseling; general guidelines on vaccination, supplementation, and accident and violence prevention. Practices were defined and judged based on the recommendations of the Ministry of Health for the organization of the work process in monitoring the growth and development of children in PHC¹⁴14 Brasil. Ministério da Saúde (MS). Saúde da criança: crescimento e desenvolvimento. Brasília: MS; 2012.. In the case of guidance on growth and development, when professionals only said whether the weight, head circumference, length, and development were within normal limits without offering any guidance, the observer coded the answer as “no”. Regarding monitoring growth and development through the CHB, a maximum interval of three months was allowed regarding records in the growth curves and a minimum of three notes for the development’s milestones.

The start and finish times were also recorded during the appointments. Appointments lasting ≥10 minutes were considered adequate, and those that lasted <10 minutes were considered inadequate¹⁵15 Halfon N, Stevens GD, Larson L, Olson LM. Duration of a Well-Child Visit: Association with Content, Family-Centeredness, and Satisfaction. Pediatrics 2011; 128(4):657-664..

The children’s mothers were asked two questions at the end of the appointment: 1 - “Did you ask all the questions you wanted to ask during the appointment?”, with two answers (yes and no); 2 - “How do you consider the appointment time?”, with three answers (very adequate, adequate, and inadequate) and grouped for analysis in the categories very adequate/adequate and inadequate. The mothers who answered that they asked everything they wanted and considered the appointment time very adequate/adequate were satisfied with the appointment¹⁵15 Halfon N, Stevens GD, Larson L, Olson LM. Duration of a Well-Child Visit: Association with Content, Family-Centeredness, and Satisfaction. Pediatrics 2011; 128(4):657-664..

Measures adopted to avoid biases

The study’s field team comprised health professionals and students with previous fieldwork experience supervised by a qualified professional. The study’s quality control included training and standardization of interviewers, construction of the Instructions Manual, and conducting a pilot study in Campina Grande, Paraíba.

Data were organized into electronic spreadsheets and double-entered in a custom database with consistency checks and interval restrictions. The Epi Info Software Validate application version 3.3.2 was used to analyze data consistency.

Study variables

We considered the following as parameters of the structure of health facilities: i) The availability of own office for the childcare appointment (yes, no), children’s scale (yes, no), anthropometer (yes, no), and CHB (yes, no); ii) The characteristics of the professionals who performed childcare appointments based on the professional relationship type (public examination, contracted), seniority in the current position (two years and over, less than two years) and postgraduate or residency in Collective Health/Family Health (yes, no); iii) Recording and interpretating anthropometric indices head circumference/age, weight/age, length/age, and body mass/age index based on child growth curves (adequate, inadequate).

Regarding the actions developed by professionals in childcare appointments, we analyzed whether the following procedures were performed: i) weight, length, and head circumference measurements and development assessment; ii) guidance based on weight, length, head circumference, and development; iii) recording weight, length, head circumference, body mass index, and development in the CHB; iv) monitoring weight, length, head circumference, body mass index, and development through the CHB; v) using the food consumption marker form in PHC, asking about the children’s diet, and advising on the children’s feeding; vi) guidelines on vaccination, supplementation, and accident and violence prevention.

We also analyzed the duration of the appointment (adequate, inadequate), satisfaction regarding the possibility of asking questions during the appointment (yes, no), satisfaction with the duration of the appointment (yes, no), and general satisfaction with the appointment (yes, no) as study variables.

Statistical methods

We analyzed the association of variables related to the structure of health units and actions developed with the health team type (PMM, conventional), the duration of the appointments, satisfaction with the appointments, and possible associations of the variables related to the actions developed and the duration of the appointments with the clients’ general satisfaction. The chi-square or Exact Fisher’s tests were used (for cases with frequency <5). We admitted a significance level of 5% and adopted the Stata version 12.0 software.

Ethical considerations

The Research Ethics Committee of the Paraíba State University approved the research project under Opinion No. 2.219.604. The mothers/guardians of children and health professionals who participated in the research signed the informed consent form, a necessary condition for participating in the study.

Results

The research totaled 22 health teams (11 of the PMM and 11 conventional). Table 1 shows the characteristics of the studied health units’ structure. Most units have their own office for childcare appointments (n=20), a children’s scale, an anthropometer (n=21), and a CHB (n=18). Fourteen professionals who performed childcare appointments had a professional relationship by public examination, and 13 had a minimum of two years of seniority in the health team. Regarding the use of child growth curves, 16 participants recorded and adequately interpreted the weight/age and length/age indices. The body mass/age index was the most deficient (more than half of the professionals could not record and interpret it correctly), followed by head circumference/age. PMM and conventional health teams showed no differences regarding structure items.

We identified 175 childcare appointments, 84 in PMM, and 91 in conventional teams. Table 2 shows the main results of the actions developed by health professionals during their appointments. Weight and length were measured in all of them, with head circumference in 96.0%, while development assessment occurred in 21.7% of the cases. Growth and development guidelines ranged from 11.4% (development) to 38.3% (weight). The weight, length, and head circumference measurements during appointments were recorded in 65.7%, 54.3%, and 50.3% of weight/age, length/age, and head circumference/age in CHB graphs, respectively. Completion of body mass index/age (11.4%) and development milestones (12.0%) curves had low frequencies. Regarding continuous CHB records, we observed that only weight had a proportion of over 50%, while frequencies of less than 10% were obtained for body mass index and development. The food consumption marker form’s use was observed in only nine appointments and food counseling in 51.4%. Vaccination guidelines (64.0%) were more frequent than supplementation (25.7%) and accident and violence prevention (2.9%).

Comparing the results by health team type, professionals from the PMM teams performed better regarding asking about (p=0.007) and questioning (p=0.001) the children’s feeding and vaccination orientation (p=0.009) and supplementation (p=0.001) (Table 2).

Sixty-three appointments (36.0%) had adequate duration, higher in the PMM teams (p=0.014). Mothers’ satisfaction with the possibility of asking questions and the duration of the appointments was greater than 85%; the overall satisfaction was 81.1%. Higher satisfaction levels were found for appointments by professionals who worked in PMM teams (p=0.006 for satisfaction with the possibility of asking questions; p=0.014 for satisfaction with the appointment’s duration; p=0.002 for overall satisfaction) (Table 3).

As can be seen in Table 4, maternal satisfaction with childcare appointments was associated with the guidelines received on weight (p=0.001), length (p=0.006), head circumference (p=0.022), development (p=0.022), food (p=0.000), vaccination (p=0.044) and supplementation (p=0.033). The professionals asking about the children’s feeding (p=0.000) and the duration of the adequate appointment (p=0.002) also produced higher client satisfaction.

Discussion

Implementing the PMM has generated interest in knowledge from the perspective of its formulation process, implementation, and results as an initiative that can reorient the care model in the health system¹⁶16 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saude Soc 2018; 27(3):794-808.. To this end, the present study compared ESF health teams with and without the PMM model. The results highlighted negligence in the professionals’ work process during childcare appointments affecting childcare, such as food consumption assessment, CHB completion, and maternal guidance related to monitoring growth and development. Also, the childcare appointments by professionals from the PMM teams had higher client satisfaction, highlighting the importance of providing guidance and the appointment duration.

As for the structure, the present study’s findings showed that most health units had adequate conditions for obtaining and recording parameters related to the children’s growth and development, unlike other studies¹⁷17 Pimentel VRM, Sousa MF, Hamann EM, Mendonça AVM. Alimentação e nutrição na Estratégia Saúde da Família em cinco municípios brasileiros. Cien Saude Colet 2014; 19(1):49-57.^,1818 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS, Borges ALV. Dificuldades no aconselhamento nutricional e acompanhamento do crescimento infantil: perspectivas de profissionais. Rev Bras Enferm 2017; 70(5):1000-1008.. However, professionals in charge of childcare appointments had unstable relationships that could adversely affect the healthcare provided¹⁹19 Figueroa Pedraza D. Percepção de enfermeiros sobre o cuidado nutricional à criança na Estratégia Saúde da Família. Saude Debate 2020; 44(124):141-151.. Moreover, findings from the national and international literature focusing on insufficient knowledge of using child growth curves, which may hinder the development of nutritional counseling actions²⁰20 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS. Capacitação em aconselhamento nutricional: avaliação de conhecimento e aplicabilidade na atenção à saúde da criança. Rev Bras Saude Matern Infant 2018; 18(1):75-82.^,2121 Nsiah-Asamoah C. Gaps in Knowledge Levels of Health Workers on recommended Child Feeding Practices and Growth Monitoring and Promotion Actions. Ped Health Res 2018; 3(2):8., were confirmed.

The underutilization and under-recording of child growth and development data listed in Brazilian literature reviews⁴4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19.^,55 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.^,2222 Caminha MFC, Silva SL, Lima MC, Azevedo PTACC, Figueira MCS, Batista Filho M. Vigilância do desenvolvimento infantil: análise da situação brasileira. Rev Paul Pediatr 2017; 35(1):102-109. were confirmed in the current study. The incipient adoption of child growth and development guidelines observed also reinforces the findings of other national⁴4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19.^,2323 Figueroa Pedraza D, Santos IS. Assessment of growth monitoring in childcare visits at the Family Health Strategy in two municipalities of Paraíba State, Brazil. Epidemiol Serv Saude 2017; 26(4):847-855. and international²⁴24 Billah SM, Saha KK, Khan ANS, Chowduhry AH, Garnett SP, Arifeen SE, Menon P. Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh. PLoS One 2017; 12(5):e0178121.^,2525 Bolka H, Abajobir AA. The practice of essential nutrition actions in healthcare deliveries of Shebedino District, South Ethiopia. Adv Reproduct Sci 2014; 2(1):8-15. studies. These circumstances indicate inadequate preparation and awareness of professionals with child healthcare and the support of the hegemonic care model in which the biologist and curative view of the health-disease process predominates. As a result, it is possible to compromise the identification of risk situations for the children’s growth and development, the communication between health professionals, the professional-client bond, care continuity, and comprehensiveness⁴4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19.^,55 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.^,1818 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS, Borges ALV. Dificuldades no aconselhamento nutricional e acompanhamento do crescimento infantil: perspectivas de profissionais. Rev Bras Enferm 2017; 70(5):1000-1008.^,2323 Figueroa Pedraza D, Santos IS. Assessment of growth monitoring in childcare visits at the Family Health Strategy in two municipalities of Paraíba State, Brazil. Epidemiol Serv Saude 2017; 26(4):847-855..

Specifically, attention is drawn to the little importance attributed to body mass index, head circumference, and development, as per previous reports in the literature⁵5 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.^,2222 Caminha MFC, Silva SL, Lima MC, Azevedo PTACC, Figueira MCS, Batista Filho M. Vigilância do desenvolvimento infantil: análise da situação brasileira. Rev Paul Pediatr 2017; 35(1):102-109.^,2323 Figueroa Pedraza D, Santos IS. Assessment of growth monitoring in childcare visits at the Family Health Strategy in two municipalities of Paraíba State, Brazil. Epidemiol Serv Saude 2017; 26(4):847-855.. This situation becomes particularly special in the current situation of Brazilian children, in which overweight and developmental problems are a concern, signaling the importance of adequate surveillance of child neurodevelopment⁵5 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.^,2222 Caminha MFC, Silva SL, Lima MC, Azevedo PTACC, Figueira MCS, Batista Filho M. Vigilância do desenvolvimento infantil: análise da situação brasileira. Rev Paul Pediatr 2017; 35(1):102-109.^,2323 Figueroa Pedraza D, Santos IS. Assessment of growth monitoring in childcare visits at the Family Health Strategy in two municipalities of Paraíba State, Brazil. Epidemiol Serv Saude 2017; 26(4):847-855.^,2626 Reichert APS, Nóbrega VM, Damasceno SS, Collet N, Eickmann SH, Lima MC. Vigilância do desenvolvimento infantil: práticas de enfermeiras após capacitação. Rev Eletr Enf 2015; 17(1):117-123.. Also, the setting revealed reinforces the devaluation of food consumption markers, food guidelines, and advice on supplementation¹⁷17 Pimentel VRM, Sousa MF, Hamann EM, Mendonça AVM. Alimentação e nutrição na Estratégia Saúde da Família em cinco municípios brasileiros. Cien Saude Colet 2014; 19(1):49-57.^,1818 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS, Borges ALV. Dificuldades no aconselhamento nutricional e acompanhamento do crescimento infantil: perspectivas de profissionais. Rev Bras Enferm 2017; 70(5):1000-1008.^,2020 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS. Capacitação em aconselhamento nutricional: avaliação de conhecimento e aplicabilidade na atenção à saúde da criança. Rev Bras Saude Matern Infant 2018; 18(1):75-82.^,2727 Nascimento FA, Silva AS, Jaime PC. Cobertura da avaliação do consumo alimentar no Sistema de Vigilância Alimentar e Nutricional Brasileiro: 2008 a 2013. Rev Bras Epidemiol 2019; 22:E190028.

28 Brito VRS, Vasconcelos MGL, Diniz AS, França ISX, Pedraza DF, Peixoto JBS, Paiva AA. Percepção de profissionais de saúde sobre o programa de combate à deficiência de vitamina A. Rev Bras Promo Saude 2016; 29(1):93-99.^-2929 Azeredo CM, Cotta RMM, Silva LS, Franceschini SCC, Sant'Ana LFR, Lamounier JA. A problemática da adesão na prevenção da anemia ferropriva e suplementação com sais de ferro no município de Viçosa (MG). Cien Saude Colet 2013; 18(3):827-836., which are essential activities for promoting healthy eating and preventing nutritional deficiencies³⁰30 Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, Pires ACL, Alves MFM, Faller LA. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e39..

The still incipient literature on the work of ESF health professionals in preventing accidents and violence in childcare appointments³¹31 Santos JS, Yakuwa MS. A Estratégia Saúde da Família frente à violência contra crianças: revisão integrativa. Rev Soc Bras Enferm Ped 2015; 15(1):38-43.

32 Goes FGB, Silva MA, Paula GK, Oliveira LPM, Mello NC, Silveira SSD. Nurses' contributions to good practices in child care: an integrative literature review. Rev Bras Enferm 2018; 71(Supl. 6):2808-2817.^-3333 Mendonça CS, Machado DF, Almeida MAS, Castanheira ESL. Violência na Atenção Primária em Saúde no Brasil: uma revisão integrativa da literatura. Cien Saude Colet 2010; 25(6):2247-2257. highlights the importance of the results of the current study, focusing on the lack of professional involvement in preventing accidents and violence through guidelines. Coping with violence in PHC in Brazil is far from the daily work and the necessary public health and sociocultural perspective, as specific care based on the complaint-behavior³³33 Mendonça CS, Machado DF, Almeida MAS, Castanheira ESL. Violência na Atenção Primária em Saúde no Brasil: uma revisão integrativa da literatura. Cien Saude Colet 2010; 25(6):2247-2257. prevails, which may explain the findings in the present study. In this sense, we should emphasize the relevance of building effective communication, trust, professional-client bond, and collaborative practices, given the recognition of violence as a public health issue and the need for actions to counteract it adequately³¹31 Santos JS, Yakuwa MS. A Estratégia Saúde da Família frente à violência contra crianças: revisão integrativa. Rev Soc Bras Enferm Ped 2015; 15(1):38-43.

32 Goes FGB, Silva MA, Paula GK, Oliveira LPM, Mello NC, Silveira SSD. Nurses' contributions to good practices in child care: an integrative literature review. Rev Bras Enferm 2018; 71(Supl. 6):2808-2817.^-3333 Mendonça CS, Machado DF, Almeida MAS, Castanheira ESL. Violência na Atenção Primária em Saúde no Brasil: uma revisão integrativa da literatura. Cien Saude Colet 2010; 25(6):2247-2257..

In the current study, we identified a better performance of PMM professionals in the guidance on food, vaccination, and supplementation, reinforcing the evidence of the Program’s contributions to health promotion, disease prevention, and comprehensive care¹⁶16 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saude Soc 2018; 27(3):794-808.^,3434 Comes Y, Trindade JS, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, Arruda CAM, Santos LMP. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Cien Saude Colet 2016; 21(9):2729-2738.. The results of the PMM are related to improvements in the infrastructure of health services, the doctor-patient relationship, and the training and continuing education of doctors¹¹11 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796.^,1616 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saude Soc 2018; 27(3):794-808.^,3535 Facchini LA, Batista SR, Silva Jr AG, Giovanella L. O Programa Mais Médicos: análises e perspectivas. Cien Saude Colet 2016; 21(9):2652.. Thus, the insufficient knowledge and practices of health professionals who participated in this research raise the need for their qualification to monitor growth and development through continuing education strategies, as recognized in the literature⁴4 Figueroa Pedraza D. Growth surveillance in the context of the primary public healthcare service network in Brazil: literature review. Rev Bras Saúde Matern Infant 2016; 16(1):7-19.^,55 Almeida AC, Mendes LC, Sad IR, Ramos EG, Fonseca VM, Peixoto MVM. Uso de instrumento de acompanhamento do crescimento e desenvolvimento da criança no Brasil - revisão sistemática de literatura. Rev Paul Pediatr 2016; 34(1):122-131.^,2020 Palombo CNT, Fujimori E, Toriyama ATM, Duarte LS. Capacitação em aconselhamento nutricional: avaliação de conhecimento e aplicabilidade na atenção à saúde da criança. Rev Bras Saude Matern Infant 2018; 18(1):75-82.

21 Nsiah-Asamoah C. Gaps in Knowledge Levels of Health Workers on recommended Child Feeding Practices and Growth Monitoring and Promotion Actions. Ped Health Res 2018; 3(2):8.^-2222 Caminha MFC, Silva SL, Lima MC, Azevedo PTACC, Figueira MCS, Batista Filho M. Vigilância do desenvolvimento infantil: análise da situação brasileira. Rev Paul Pediatr 2017; 35(1):102-109.^,2626 Reichert APS, Nóbrega VM, Damasceno SS, Collet N, Eickmann SH, Lima MC. Vigilância do desenvolvimento infantil: práticas de enfermeiras após capacitação. Rev Eletr Enf 2015; 17(1):117-123.^,3030 Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, Pires ACL, Alves MFM, Faller LA. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e39.

31 Santos JS, Yakuwa MS. A Estratégia Saúde da Família frente à violência contra crianças: revisão integrativa. Rev Soc Bras Enferm Ped 2015; 15(1):38-43.

32 Goes FGB, Silva MA, Paula GK, Oliveira LPM, Mello NC, Silveira SSD. Nurses' contributions to good practices in child care: an integrative literature review. Rev Bras Enferm 2018; 71(Supl. 6):2808-2817.^-3333 Mendonça CS, Machado DF, Almeida MAS, Castanheira ESL. Violência na Atenção Primária em Saúde no Brasil: uma revisão integrativa da literatura. Cien Saude Colet 2010; 25(6):2247-2257.. In this sense, we should mention the importance of training guided by the comprehensive care model, which is one of the significant challenges of Brazilian PHC³⁶36 Arantes LJ, Shimizu HE, Merchán-Hamann E. Contribuições e desafios da Estratégia Saúde da Família na Atenção Primária à Saúde no Brasil: revisão da literatura. Cien Saude Colet 2016; 21(5):1499-509.. We highlight the PMM’s potential for improving learning processes and in-service training¹¹11 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796..

Regarding the duration of appointments, we identified their commitment, agreeing with the literature¹⁵15 Halfon N, Stevens GD, Larson L, Olson LM. Duration of a Well-Child Visit: Association with Content, Family-Centeredness, and Satisfaction. Pediatrics 2011; 128(4):657-664.^,2323 Figueroa Pedraza D, Santos IS. Assessment of growth monitoring in childcare visits at the Family Health Strategy in two municipalities of Paraíba State, Brazil. Epidemiol Serv Saude 2017; 26(4):847-855.^,3737 Surbakti EF, Sari K. The Relationship Between Consultation Length and Patient Satisfaction: A Systematic Review. KnE Life Sci 2018; 2018:41-49.^,3838 Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017; 7:e017902.. Despite this, we observed high client satisfaction with this parameter, possibly as a condition related to the low level of expectations³⁹39 Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.. However, the duration of the childcare appointment should be analyzed, regardless of the level of satisfaction generated, due to its capacity to influence the number of actions developed, the client’s interaction with the professionals, and the quality of care provided¹⁵15 Halfon N, Stevens GD, Larson L, Olson LM. Duration of a Well-Child Visit: Association with Content, Family-Centeredness, and Satisfaction. Pediatrics 2011; 128(4):657-664.^,2424 Billah SM, Saha KK, Khan ANS, Chowduhry AH, Garnett SP, Arifeen SE, Menon P. Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh. PLoS One 2017; 12(5):e0178121.^,3737 Surbakti EF, Sari K. The Relationship Between Consultation Length and Patient Satisfaction: A Systematic Review. KnE Life Sci 2018; 2018:41-49.^,3838 Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017; 7:e017902.. The professionals’ workload, exhaustion, efficiency, and satisfaction can significantly influence the duration of the appointment³⁷37 Surbakti EF, Sari K. The Relationship Between Consultation Length and Patient Satisfaction: A Systematic Review. KnE Life Sci 2018; 2018:41-49.^,3838 Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017; 7:e017902..

In Brazil, according to the results of the present study, high satisfaction levels have been recorded regarding the doctors’ explanations (91%) and the time they make available for questions (85%)⁴⁰40 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saude Debate 2018; 42(n. esp.):18-37.. Additionally, clients are more satisfied with the services they receive when they solve their problems and feel respected⁴¹41 Protasio APL, Gomes LB, Machado LS, Valença AMG. Satisfação do usuário da Atenção Básica em Saúde por regiões do Brasil: 1º ciclo de avaliação externa do PMAQ-AB. Cien Saude Colet 2017; 22(6):1829-1844., which shows the plausibility of the results presented in this study. As for the greater satisfaction among PMM clients (90.5%), we observe an agreement with what was observed in 32 municipalities in all regions of the country, where being satisfied was associated with the doctors’ technical and humanized performance⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.. In the rural area of Porto Velho (RO), a survey of 96 clients from seven health units highlighted the preference for care and communication by PMM doctors⁴²42 Santos MAM, Souza EG, Cardoso JC. Avaliação da qualidade da Estratégia Saúde da Família e do Programa Mais Médicos na área rural de Porto Velho, Rondônia. Rev Eletr Gest Soc 2016; 10(26):1327-1346.. Literature reviews confirm the positive assessment of the PMM based on client satisfaction¹¹11 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796.^,1616 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saude Soc 2018; 27(3):794-808..

The association recorded in this research between maternal satisfaction with childcare appointments, the guidance received during the session, and its duration, can be explained by the clients’ appreciation of the professionals’ dedication to providing information and advice²¹21 Nsiah-Asamoah C. Gaps in Knowledge Levels of Health Workers on recommended Child Feeding Practices and Growth Monitoring and Promotion Actions. Ped Health Res 2018; 3(2):8.^,3737 Surbakti EF, Sari K. The Relationship Between Consultation Length and Patient Satisfaction: A Systematic Review. KnE Life Sci 2018; 2018:41-49., facilitated by longer appointment period²⁴24 Billah SM, Saha KK, Khan ANS, Chowduhry AH, Garnett SP, Arifeen SE, Menon P. Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh. PLoS One 2017; 12(5):e0178121.^,3737 Surbakti EF, Sari K. The Relationship Between Consultation Length and Patient Satisfaction: A Systematic Review. KnE Life Sci 2018; 2018:41-49.. Consistent findings were obtained in another study, in which client satisfaction was directly linked to the doctors’ interest during care⁴²42 Santos MAM, Souza EG, Cardoso JC. Avaliação da qualidade da Estratégia Saúde da Família e do Programa Mais Médicos na área rural de Porto Velho, Rondônia. Rev Eletr Gest Soc 2016; 10(26):1327-1346.. Another survey showed that PMM clients were satisfied with the care and the information received from the doctors⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.. Our study adds empirical evidence that suggests the meaning attributed by mothers to the guidelines they received during childcare appointments.

The population assisted by PMM professionals has received better care during childcare appointments than those attended by traditional ESF teams, with more guidance and a higher satisfaction level. These findings add to those reported that emphasize the benefits of the PMM in the quality of services, the doctor-patient relationship, the development of interdisciplinary practices, and expanded actions, including health promotion⁷7 Comes Y, Trindade JS, Shimizu HE, Hamann EM, Bargioni F, Ramirez L, Sanchez MN, Santos LMP. Avaliação da satisfação dos usuários e da responsividade dos serviços em municípios inscritos no Programa Mais Médicos. Cien Saude Colet 2016; 21(9):2749-2759.^,1111 Kemper ES, Mendonça AVM, Sousa MF. Programa Mais Médicos: panorama da produção científica. Cien Saude Colet 2016; 21(9):2785-2796.^,1616 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saude Soc 2018; 27(3):794-808.^,3434 Comes Y, Trindade JS, Pessoa VM, Barreto ICHC, Shimizu HE, Dewes D, Arruda CAM, Santos LMP. A implementação do Programa Mais Médicos e a integralidade nas práticas da Estratégia Saúde da Família. Cien Saude Colet 2016; 21(9):2729-2738.. Regarding childcare, a study conducted in the Federal District showed an improved offer after implementing the PMM⁴³43 Moreira ACG, Costa EPSR, Almeida RP, Constâncio TB, Gottems LBD, Arrais A, Oliveira MLC. Programa mais médicos: análise a partir de um modelo lógico. Com Cien Saude 2017; 28(3/4):291 302.. Thus, reading the present article is expected to contribute to understanding the importance of transforming child healthcare practices into “Health Promotion and Care Trails”.

In interpreting the presented results, we suggest considering possible limitations related to the direct observation of the provision of services and the client’s satisfaction. In the first case, the professionals may have offered a complete service, with overestimations that make undervalued practices even very troubling. Applying a questionnaire right after the appointments can induce a gratitude bias expressed through greater satisfaction. However, observing the appointments and the scope of the research emerge as differentials that presuppose reliability and generalization. Thus, we propose developing other studies with different methodological designs, notably focusing on effectiveness assessments and problems perceived by the different spheres of the health system.

Based on our evaluation, we identified that the implementation of childcare appointments by professionals has significant gaps that can influence maternal satisfaction. In the professionals’ work process, we highlight the underreporting of growth and development data in the CHB, the low involvement in client guidance practices, and the short duration of appointments. In assessing satisfaction, we highlight the importance of receiving guidance and the appointment duration, with better evaluation in the PMM teams. Thus, there is an urgent need for feasible strategies to improve healthcare during childcare appointments in public health services.

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