Abstracts

INTRODUCTION

The Unified Health System (SUS), in Brazil, has allowed a rapid expansion of primary care, with significantly positive results in the provision of services and indicators of access to health care by the population¹1 . Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779): 1778-97.. Despite the progress made, there are still challenges to overcome²2 . Victora CG, Barreto ML, Carmo LM, Monteiro CA, Schmidt MI, Paim J, et al. Lancet Brazil Series Working Group. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782): 2042-53.. Since 1994, when the first Family Health Strategy (FHS) teams were deployed, the strengthening of health actions has been discussed, with emphasis on promotion activities and strategies to change the care model, previously hospital-centered and focused on medical consultations.

It is natural to assume that the changes in the care model involve having a better knowledge of the characteristics of assisted demand, among other things. Self-perception of health conditions has been employed as a measure that is able to reflect an integrated concern of the individual in the biological, psychological and social dimensions³3 . Nunes APN, Barreto SM, Gonçalves LG. Relações sociais e autopercepção da saúde: Projeto Envelhecimento e Saúde Rev Bras Epidemiol 2012; 15(2): 415-28.. The use of associated epidemiological data can be very useful for the design of appropriate care strategies for users, including the morbidity statistics⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... .

There are few studies in the country on the profile of morbidities that affect people assisted by primary care. The Primary Health Care Information System (SIAB), which is the official record of the major morbidities assisted by the FHS also has weaknesses and does not provide necessary and reliable information for the identification of morbidities⁵5 . Silva AS, Laprega MR. Avaliação crítica do Sistema de Informação da Atenção Básica (SIAB) e de sua implantação na região de Ribeirão Preto, São Paulo, Brasil. Cad Saúde Pública 2005; 21(6): 1821-8..

In principle, the reality on the morbidity of primary care users demands, in addition to the development of standardized electronic medical records, training for FHS workers. Classification and coding of diagnoses, complaints and health needs of patients is a fundamental step in this process. In this context, the International Classification of Primary Care, in its second edition (ICPC-2), constitutes an important contribution in the knowledge of morbidity at this level of care⁶6 . WONCA (Organização Mundial dos Médicos da Família): Classificação internacional de atenção primária, CIAP-2, Sociedade Brasileira de Medicina da Família, Florianópolis, 2009.. The coding system is relatively simple and easy, and has been used in many countries⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. ^{, 8}8 . Soler JK, Okkesb I, Woodc M, Lambertsb H. The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care. Family Practice Advance. 2008; Available from: http://fampra.oxfordjournals.org/
http://fampra.oxfordjournals.org/... .

Given the lack of electronic medical records, surveys based on interviews or printed medical records can provide important information. The information obtained from the surveys help to identify the epidemiological profile of the population, assist health policy and allow inferences on different health dimensions⁹9 . Theme Filha MM, Szwarcwald CL, Souza Júnior PRB. Medidas de morbidade referida e inter-relações com dimensões de saúde. Rev Saúde Pública 2008; 42(1): 73-81.. Also, the various aspects of accessibility to health services can be identified by the survey¹⁰10 . Barros MBA. Inquéritos domiciliares de saúde: potencialidades e desafios. Rev Bras Epidemiol 2008; 11(Suppl 1): 6-19.. This study aimed to characterize the profile of morbidity reported by users of the FHS teams in the Northeast macroregion of Minas Gerais, based on ICPC-2.

METHODOLOGY

This is a cross-sectional, population-based study that was developed in the Northeast macroregion of Minas Gerais with the FHS teams. The region consists of 63 municipalities and is one of the poorest areas of the country, incorporating Vale do Jequitinhonha and Vale do Mucuri, with a Human Development Index below 0.65 as the general average. During data collection, there was a record of 268 FHS teams, including teams of Community Health Agents (CHA) for a population of approximately 917,000 inhabitants. Adolescents and adults who use the service and are registered by the Family Health teams in the region studied were eligible for this study.

During data collection, semi-structured questionnaires developed especially by the researchers were used. They were based on similar studies in the literature¹¹11 . Gusso GDF. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2ª edição (CIAP-2). [Tese] USP: São Paulo; 2009. and on the objectives of the study. The questionnaires were adapted for three professional categories from the family health teams: doctors, nurses and community health agents (CHA), which were considered by the investigators as having greater contact with the morbidity demands of the population. Data collection was performed on a specific day, previously defined ("one single day morbidity"¹²12 . Silva N, Mendis K. One-day general practice morbidity survey in Sri Lanka. Family Practice 1998; 15(4): 323-31. ^{, 13}13 . Emmanuel SC, Tan BY, Chan KW. A one-day morbidity survey of outpatients. Singapore Fam Physician 1989; 15: 171-97.), after intensive mobilization of health managers, coordinators and primary care professionals. All professionals were asked to complete a questionnaire for each user assisted on a predetermined day, with notes of some sociodemographic variables (age, gender, origin, education), as well as and health information (diagnosis, complaint or health problem). Data were collected from July to December 2011 in one single day for each health team.

Before conducting the research, a pilot study was conducted on a randomly selected area with the aim of testing the instruments for data collection and the proposed methodology. No adjustments to the data collection instruments were required.

For data analysis, instruments that were incorrectly or illegibly filled, as well as those by users coming from municipalities outside the predetermined region, were excluded. Data were analyzed using the SPSS software, version 16.0. All complaints and health problems recorded were classified according to the International Classification of Primary Care, second version (ICPC-2), a procedure performed by a single person previously qualified in order to avoid distortions of classification. The proportions of diagnoses, complaints and health problems in different systems (chapters if ICPC-2) were compared between genders using the χ² test, assuming a significance level of 5% (p < 0.05).

All ethical aspects were observed, and the project was previously approved by the Research Ethics Committee of Universidade Estadual de Montes Claros (Protocol no. 2314/2010). Interviews were conducted with the permission of the municipal managers and workers in family health teams and all respondents, in the context of teams from the Northeast macroregion of Minas Gerais, upon signature of an informed consent. There was no conflict of interest for conducting the study.

RESULTS

Of the 268 teams registered in the region, 64 were excluded because the managers and/or coordinators did not effectively support or refused to conduct the data collection in their municipalities. Thus, data from 204 family health teams were collected. In total, 17,988 people participated in the study, 10,855 (60.3%) were females and 7,133 (39.7%) were males. Of these, 1,662 (9.2%) corresponded to care by physicians, 2,530 (14.1%), care by nurses and 13,796 (76.7%) corresponded to visits and meetings with CHA. The reported morbidity was divided into 'diagnoses', when the treatment was given by doctors, in 'complaints or reasons for visits', when the treatment was carried out by nurses and 'health problems' when the data resulted from meetings with community health agents during home visits. The main characteristics and patterns of morbidity are presented in Tables 1 to 3, according to the type of professional from the FHS and chapters of ICPC-2. Twenty-five forms were excluded due to illegibility.

Among doctor visits (Table 1), a higher prevalence was observed in females (67.6%) who were in the 40-59 years old age range (31.9%). Among the consultations recorded by physicians, 93 people (5.6%) did not receive diagnosis after consultations. The most common diagnoses were related to pathologies from chapters of the circulatory system (n = 253; 15.2%), diseases of the musculoskeletal system (n = 225; 13.5%) and digestive system diseases (n = 202; 12.1%).

Table 2 presents the main characteristics and complaints/reasons for visits of adult patients assisted by FHS nurses. A greater proportion of visits to the younger population was observed, with a prevalence of the 20-39 years old age range (n = 1,048; 41.4%). In this group, women accounted for the highest number of visits (n = 1,870; 73.9%). Schooling was also assessed for this population, which identified that the majority of the care was given to people who had not completed primary school.

The main complaints were related to the chapter of "general and non-specific causes," totaling 590 visits (23.3%), followed by complaints in the chapter of female genital tract, with 445 visits (17.6%), and 433 visits due to pregnancy or family planning (17.1%).

Table 3 presents the main characteristics and health problems referred to CHA by FHS users. There was a predominance of people with low education, including 2,542 (18.4%) illiterate individuals. Health problems reported refer to those presented in the 15 days previous to the data collection. Among the people interviewed by the CHA, 3,338 (24.2%) reported some complaint or health problem in the previous 15 days. Most respondents comprised a younger population, aged between 20 and 39 years (33.7%), being mostly women (57.0%). Regarding complaints/health problems recorded by the CHA, the main ones refer to the chapter of the respiratory tract (n = 518; 15.5%), musculoskeletal system (n = 493; 14.8%) and cardiovascular system (n = 449; 13.5%).

Table 4 presents the main diagnoses, health complaints and problems assigned to users in the study in each system or chapter of ICPC-2.

DISCUSSION

This study characterized the profile of reported morbidity by FHS users in the Northeast macroregion of Minas Gerais and, although the demand for medications and immunizations was not considered, it helped identify the main health problems that reach primary care teams in the region studied. The recorded results revealed the main diagnoses of people assisted by the medical teams evaluated, stressing the importance of cardiovascular (especially hypertension), musculoskeletal (especially back pain) and digestive tract (especially intestinal parasites) diseases, which together account for over 40% of consultations. Respiratory and endocrine disorders also represent important causes of morbidity. These results are different from those observed in the study by Gusso¹¹11 . Gusso GDF. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2ª edição (CIAP-2). [Tese] USP: São Paulo; 2009., who pointed out, in the distribution of morbidity by chapters of ICPC-2, cardiovascular diseases, general and nonspecific complaints and respiratory diseases as the three main groups of most frequent causes. However, a broader analysis of the most frequent problems identified in this study allows greater similarity, since most referred chapters coincide with this study. The work by Gusso is the most recent and comprehensive national study of the demand in primary care, although it was restricted to just one city¹¹11 . Gusso GDF. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2ª edição (CIAP-2). [Tese] USP: São Paulo; 2009.. Other national studies are restricted to the characterization of the demand for a single unit¹⁴14 . Pimentel IRS, Coelho BC, Lima JC, Ribeiro FG, Sampaio FPC, Pinheiro RP, et al.Caracterização da demanda em uma Unidade de Saúde da Família. Florianópolis. Rev Bras Med Fam Comunidade 2011; 6(20): 175-81., of specific groups¹⁵15 . Silva DMPP, Tomanik EA. Morbidade referida por moradores ribeirinhos de Porto Rico, PR, Brasil. Rev Bras Enferm 2010; 63(3): 452-8., or are older studies¹⁶16 . Cesar CLG, Laurenti R, Buchala CM, Figueredo G M, Carvalho WO,Carantin CVS. Uso da Classificação Internacional de Doenças em inquéritos de saúde. Rev Bras Epidemiol 2001; 4(2): 120-9..

Even though the morbidity patterns are highly sensitive to social, environmental and economic contexts¹⁷17 . Szwarcwald CL, Leal MC, Gouveia GC, Souza WV. Desigualdades socioeconômicas em saúde no Brasil: resultados da Pesquisa Mundial de Saúde, 2003. Rev Bras Saúde Matern Infant 2005; 5(Suppl 1): S11-S22. , it is noteworthy that international studies also point to circulatory diseases⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 18}18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... , respiratory diseases⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. ^{, 18}18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... , musculoskeletal problems⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. and disorders of the digestive system⁷7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. ^{, 18}18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... as their biggest demands, which is consonant with the results of this study. It is natural to assume, therefore, that these are common demands for doctors of primary care services.

Complaints or reasons for visits registered by nurses highlighted mainly general and non-specific signs and symptoms consultations relating to women's health. Probably, the highlight observed for general and non-specific signs and symptoms are reflecting the welcoming and managerial role of the nursing professional¹⁹19 . Ximenes Neto, FRG. Sampaio JJC. Gerentes do território na Estratégia Saúde da Família: análise e perfil de necessidades de qualificação. Rev Bras Enferm 2007; 60(6): 687-95.. Generally, this professional takes the coordination of care in primary health units and ultimately serves as a reference for users in many of their visits to health facilities. It is also important to highlight that a high proportion of patients without a definite diagnosis, or even without a target system defined, is common in primary care¹¹11 . Gusso GDF. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2ª edição (CIAP-2). [Tese] USP: São Paulo; 2009.. The visits related to women's health are also compatible with the role of the FHS nurse, who, traditionally, in the organization of care activities, shares the activities of cervical cancer preventive examinations, monitoring of risk pregnancies and guidance for family planning with the doctors²⁰20 . Rodrigues EM, Nascimento RG, Araújo A. Protocolo na assistência pré-natal: ações, facilidades e dificuldades dos enfermeiros da Estratégia de Saúde da Família. Rev Esc Enferm USP 2011; 45(5): 1041-7..

Regarding the records of CHA, it is worth noting that the problems most frequently reported by users correspond to a mixture of the main groups of problems or complaints reported by doctors and nurses. The top five health problems recorded by CHA account for over 60% of all reported problems. This trend, of a few diagnoses representing an important contingent of demand in primary care, has been reported in other studies⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 18}18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... . This finding underscores the importance of using ICPC-2 in categorizing problems assisted in primary care. Codes can facilitate the communication of data within the same team and the exchange of information between FHS teams.

ICPC-2 works with a simple coding system on two levels: the first defines the organic system (represented by 17 chapters) and the second defines seven components (represented by numbers), that discriminate: (1) complaints and symptoms, (2) diagnostic and preventive screening, (3) medications, treatments and therapeutic procedures, (4) results of examinations, (5) administrative component, (6) follow-up and other reasons for consultation and (7) diagnoses and diseases⁶6 . WONCA (Organização Mundial dos Médicos da Família): Classificação internacional de atenção primária, CIAP-2, Sociedade Brasileira de Medicina da Família, Florianópolis, 2009. ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12.. There is also the possibility of inclusion of gravity in the code, which broadens slightly the complexity of the classification. Naturally, the same health problem can be classified in different ways, according to the perception of the health care professional who performs the encoding, their degree of certainty about the 'diagnosis' and their familiarity with the coding process. Different encodings for the same episode of care in primary care does not imply inadequacy of the coding system and does not affect the recognition of the morbidity profile of a population group⁸8 . Soler JK, Okkesb I, Woodc M, Lambertsb H. The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care. Family Practice Advance. 2008; Available from: http://fampra.oxfordjournals.org/
http://fampra.oxfordjournals.org/... . A recent national study reported good interobserver reliability using the ICPC-2, which indicates a good performance of the classification code for reasons of care in primary care, even from logs in medical records²¹21 . Sampaio MMA, Coeli CAM, Alves MGM, Soares MF, Camargo Jr KR, Moreno AB. Confiabilidade interobservador da Classificação Internacional de Atenção Primária em uma unidade de atenção básica à saúde. Rev Bras Epidemiol. 2012; 15(2): 355-62. . Other aspects of the classification tend to be better studied from computerized analyses, which is still not a reality in the country. It is worth noting that although ICPC-2 is used in several countries⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. ^{, 18}18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... , its simplification process still suffers criticism, and some authors suggest it is inadequate to meet all the complexity of clinical problems⁷7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12. ^{, 22}22 . Botsis T, Bassoe CF, Hartvigsen G.. BMC Medical Informatics and Decision Making. 2010; 10:11. Available from: http://www.biomedcentral.com/1472-6947/10/11
http://www.biomedcentral.com/1472-6947/1... .

In the present study, although there was zeal in putting a single person to classify responses recorded, the coding was done from data of the survey form and not directly from the contact with patients, a fact that undermines the diagnostic accuracy. However, the authors believe that the definition of the main chapters and major health problems within each chapter is less susceptible to coarse errors and sufficient to characterize the demand, as it is recorded in other international studies⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12.. The finding that up to 60% of the main health problems reported by users of the FHS teams are restricted to only a few chapters of ICPC-2 can assist the process of organizing the demand for these teams and alert health managers about the importance of training of health professionals, more oriented towards those needs of the assisted population.

The official system for monitoring the actions of the FHS, SIAB, although presenting has some positive aspects regarding the user interface and elaboration of reports, has some limitations. The system does not allow the knowledge of the morbidity profile and has not been able to achieve its goals. Some studies point out that the system does not offer a critical analysis of morbidity and suffers no quantitative or qualitative critic of their analysis process, often serving just as a bureaucratic instrument for the operation of teams⁵5 . Silva AS, Laprega MR. Avaliação crítica do Sistema de Informação da Atenção Básica (SIAB) e de sua implantação na região de Ribeirão Preto, São Paulo, Brasil. Cad Saúde Pública 2005; 21(6): 1821-8. ^{, 23}23 . Marcolino JS, Scochi MJ. Informações em saúde: o uso do SIAB pelos profissionais das Equipes de Saúde da Família. Rev Gaúch Enferm 2010; 31(2): 314-20..

The lack of broader or more recent national data on morbidity recorded by the FHS teams affects more detailed analysis of the observed data. Surely the lack of a computer system is a limiting factor for such studies, unlike what happens in other countries⁸8 . Soler JK, Okkesb I, Woodc M, Lambertsb H. The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care. Family Practice Advance. 2008; Available from: http://fampra.oxfordjournals.org/
http://fampra.oxfordjournals.org/... .

In general, the structure of the population assisted by teams evaluated is similar to what was observed in other studies that, highlighting higher prevalence of women and younger individuals in the demand of primary care¹⁸18 . Gataa R, Ajmi TN, Bougmiza I, Mtiraoui A. Morbidity patterns in general practice settings of the province of Sousse, Tunísia. Pan African Med Journal 2009; 3:11. Available at: http://www.panafrican-med-journal.com/content/article/3/11/full
http://www.panafrican-med-journal.com/co... . Although it was not the specific objective of this study to conduct a deeper analysis from the point of view of genders, it is important to note that, in the records of all professional categories, women showed more complaints or health problems.

In relation to medical consultations, there was homogeneity for different diagnoses among men and women, except for skin diseases and general and non-specific complaints, which were more common for men. In nursing records, in addition to the two chapters indicated, men also had higher proportions of complaints about the problems of the circulatory, digestive, nervous and musculoskeletal systems. However, considering the high demand for nursing regarding the health status of women (gynecological problems related to pregnancy and family planning), it is unreasonable to establish any inference about these differences. In the records of CHA, only the skin diseases were more prevalent among men, with no records of other gender differences in the remaining chapters of ICPC-2. Thus, in general, small differences are observed in the registration of morbidity among men and women, which is consistent with the observation by Laurenti et al²⁴24 . Laurenti R, Jorge MHPM, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Rev C S Col 2005; 10(1): 35-46.. These authors observed that, in the evaluation of morbidity between genders, measured by hospital admissions and excluding causes related to pregnancy and childbirth, there is a balance between the number of male and female hospitalizations, with a similar distribution of reasons for hospitalization, except for external causes, mental and behavioral disorders.

The similarity of some results of this study with results from international studies, especially in relation to the prevalence of circulatory (with emphasis on hypertension), musculoskeletal (with emphasis on low back pain) and respiratory (with emphasis on upper airway infections) problems, stresses the universality of these problems and the accelerated nosological/epidemiological transition experienced by the country⁴4 . Minas M, Koukosias N, Zintzaras E, Kostikas K, Gourgoulianis K. Prevalence of chronic diseases and morbidity in primary health care in central Greece: an epidemiological study. BMC Health serv Research 2010: 252. Available at: http://www.biomedcentral.com/1472-6963/10/252
http://www.biomedcentral.com/1472-6963/1... ^{, 7}7 . Brueton V, Yogeswaran P, Chandia J, Mfenyana K, Modell B, Modell M, et al . Primary care morbidity in Eastern Cape Province. S Afr med J 2010; 100(5): 309-12.. Goldbaum et al. had already highlighted, in a study carried out in São Paulo, that, for the population covered by the FHS, social aspects (income and education) do not cause significant differences in the use of and demand for health care services, indicating that the expansion of health care coverage may be contributing to greater equity in these conditions²⁵25 . Goldbaum M, Gianini RJ, Novaes HMD, César CLG. Utilização de serviços de saúde em áreas cobertas pelo programa saúde da família (Qualis) no Município de São Paulo. Rev Saúde Pública 2005; 39(1): 90-9.. In addition to the similarities, the differences should also be pointed as noticeable and worthy of continuous analyses. The high proportion of digestive diseases (with emphasis on intestinal parasites) denotes the persistence of inadequate living conditions. The low prevalence of conditions of the chapter of psychological problems such as anxiety, depression, abuse of alcohol and other drugs may denote the invisibility of these issues for the health team or the difficulty of recognition or management of these issues. Often, patients with mental health problems present nonspecific complaints or other physical problems, which are more easily identified by health teams. These represent just some of the differences that reinforce the need for regular surveys, with the potential to reveal, in deeper approaches, the role of socioeconomic inequalities on the health-disease process¹⁷17 . Szwarcwald CL, Leal MC, Gouveia GC, Souza WV. Desigualdades socioeconômicas em saúde no Brasil: resultados da Pesquisa Mundial de Saúde, 2003. Rev Bras Saúde Matern Infant 2005; 5(Suppl 1): S11-S22. . In fact, all of the observed results indicate the relevance of population-based studies on morbidity. For Barros, this would be essential for the generation of information necessary for defining new intervention policies and the evaluation of their impact on health¹⁰10 . Barros MBA. Inquéritos domiciliares de saúde: potencialidades e desafios. Rev Bras Epidemiol 2008; 11(Suppl 1): 6-19.. Population-based health surveys are important for understanding the reality of conditions occurring in the population, ranging from the well defined to uncharacteristic symptoms or signs, which often may disappear without any interference¹⁶16 . Cesar CLG, Laurenti R, Buchala CM, Figueredo G M, Carvalho WO,Carantin CVS. Uso da Classificação Internacional de Doenças em inquéritos de saúde. Rev Bras Epidemiol 2001; 4(2): 120-9..

It is important to note that the region covered in this study is one of the poorest in the country, with low socioeconomic indicators. An indirect measure of this scenario is reflected in the high percentage of people observed who are illiterate or with low education. This aspect strongly influences the disease burden and should not be overlooked. In a health survey in greater São Paulo, Barros and colleagues found that there was a significant impact of social inequality on the presence of chronic conditions reported, and the less educated segment of the population had 62% higher prevalence of chronic diseases, when compared to the most educated segment¹⁰10 . Barros MBA. Inquéritos domiciliares de saúde: potencialidades e desafios. Rev Bras Epidemiol 2008; 11(Suppl 1): 6-19..

The results of this study should be interpreted in light of some limitations. The fact that the research was carried out in a single day is one of the limiting factors, because some comorbidities may undergo seasonal effects (respiratory diseases are, for example, most common during the winter). The schedule of demand of health facilities (with groups of hypertensive patients, pregnant women, etc.) can also interfere with the results collected in a single day. However, the logistical difficulty of multiple collections and the fact that the methodology was already backed by the international literature were factors that enabled the selection of the strategy employed¹²12 . Silva N, Mendis K. One-day general practice morbidity survey in Sri Lanka. Family Practice 1998; 15(4): 323-31. ^{, 13}13 . Emmanuel SC, Tan BY, Chan KW. A one-day morbidity survey of outpatients. Singapore Fam Physician 1989; 15: 171-97..

Another limitation identified was the low participation of the doctor, with a small quantity compared to the amount of municipalities participating in the study. This influenced the study negatively, because it complicated more comprehensive diagnostics results, as only doctors can provide the patient's diagnosis.

Although the data collection instrument is easy to assimilate, with few variables, and its application occurred after training, the multiplicity of actors involved in the data collection can also be a variable that jeopardizes the validity of the final results. This is a limitation that is inherent to the method due to the virtual impossibility of a limited number of interviewers in similar studies. To compensate, even partially, its limitations, this study recorded a high contingent of participants not observed in the national literature.

CONCLUSIONS

The characteristics of primary care and the relevance it has taken in Brazil in recent years highlight the need for further research in this area. For greater effectiveness of the model assumed in the country, it is desirable that primary care determine the work of other levels of the health system, addressing the most common problems in the community and integrating the attention when there are several health problems. In this context, the morbidity and evaluative studies in the FHS services may provide the basis for strengthening primary care.

The results allowed the knowledge of the health needs of people assisted by the FHS teams, setting up a pattern of morbidity in primary care for the area evaluated. The use of ICPC-2 proved to be useful and applicable to the context of family health teams and may represent an important tool for health managers. Indirectly, these data allowed a broader knowledge of the daily workload for teams evaluated in relation to major health problems. Results of similar studies should be used in the planning of activities and continuing education programs for workers in primary care.

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