ABSTRACT:

Introduction:

Trachoma maintains itself as a public health problem and an important cause of morbidity, visual impairment and preventable blindness in Brazil.

Objective:

To analyze factors associated with treatment and control of trachoma treatment in schoolchildren diagnosed during the national campaign in 2014, in the town of Russas, Ceará.

Methodology:

A cross-sectional study was brought out from January to April 2016. Social, demographic, economic and follow-up data were collected for 390 schoolchildren aged five to 14 years old, diagnosed with trachoma in the campaign in 2014. They were defined dependent variables: trachoma treatment and control of trachoma disease, categorized as adequate and inadequate, and multivariate analyzes were performed.

Results:

Treatment was considered adequate in 56.7% of schoolchildren and in only 5.9% treatment control was classified as adequate. In the multivariate analysis, they have got an association with the trachoma treatment result: rural residence zone and waste destination in a non-public space. The last control of the treatment of trachoma remained associated to the variables: rural residence zone; family income less than a minimum wage and school not examined by the physician.

Conclusion:

Inadequate treatment and control of trachoma treatment showed an association with socioeconomic variables and follow-up of primary care. Health education activities were not accessible to the entire community, indicating the need for more involvement by primary care professionals.

Keywords:
Trachoma; Drug therapy; Control.

INTRODUCTION

Trachoma is a chronic and recurrent keratoconjunctivitis caused by Chlamydia trachomatis. It remains a public health problem and it is an important cause of visual impairment and preventable blindness in Brazil¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014.. It is considered to be the leading infectious cause of blindness worldwide and one of the 18 neglected tropical diseases (NTDs), which affect more than one billion of the world’s poorest people²2. International Coalition for Trachoma Control. Aliança da OMS para a eliminação global do tracoma até 2020. Eliminando o Tracoma: Acelerar Rumo ao 2020 [Internet]. [acessado em 30 ago. 2018]. Disponível em: Disponível em: http://www.trachomacoalition.org/2016-roadmap/portuguese.html
http://www.trachomacoalition.org/2016-ro... .

In order to eliminate trachoma as a preventable cause of blindness, in 1997, the World Health Organization (WHO) created the Alliance for the Global Elimination of Trachoma by 2020 (GET2020), with Brazil being one of the participants³3. World Health Organization. Situação mundial da visão. Visão 2020: o direito de ver 1999-2005. Síntese [Internet]. Genebra: WHO, 2005 [acessado em 12 jul. 2016]. 16 p. Disponível em: Disponível em: http://www.docplayer.com.br/12544969-Situacao-mundial-da-visao-visao-2020-o-direito-de-ver-1999-2005-sintese.html
http://www.docplayer.com.br/12544969-Sit... . To achieve this goal, the SAFE strategy is recommended:

In order to subsidize these actions aimed at eliminating trachoma in Brazil, from 2002 to 2008, the Ministry of Health (MOH) conducted a national survey on the prevalence of the disease in schoolchildren, with the goal of knowing the occurrence and distribution of this disease in the country. Then, in 2011, a plan to eliminate trachoma as a cause of blindness emerged. Its purpose was to eliminate or reduce this disease in the country⁴4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância em Doenças Transmissíveis. Plano integrado de ações estratégicas de eliminação da hanseníase, filariose, esquistossomose e oncocercose como problema de saúde pública, tracoma como causa de cegueira e controle das geo-helmintíases: plano de ação 2011-2015. Brasília: Ministério da Saúde ; 2012. 104 p.. In 2013, the first National Campaign for Leprosy, Vermin, Trachoma and Schistosomiasis took place. It was aimed at a target audience of schoolchildren aged 5 to 14 years old in the public education system. Its objectives included identifying and treating at least 80% of trachoma cases, and eliminating the disease as a cause of blindness⁵5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Coordenação Geral de Hanseníase e Doenças em Eliminação. Guia prático para operacionalização da Campanha Nacional de Hanseníase, Verminoses, Tracoma e Esquistossomose 2016. Brasília: Ministério da Saúde ; 2016. 50 p..

Some of the objectives of epidemiological surveillance of trachoma are to diagnose and treat cases with active infection, by adopting relevant prevention and control measures, in addition to controlling the occurrence of trachoma through regular surveys/active searches for cases and home visits for contacts¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014..

According to worldwide estimates, in 2010, approximately 2.2 million people were visually impaired due to trachoma, of which 1.2 million had irreversible blindness⁶6. Pascolini D, Mariotti SP. Global estimates of visual impairment. Br J Ophthalmol [Internet]. 2012 [acessado em 30 ago. 2018]; 96(5): 614-8. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/22133988 . http://doi.org/10.1136/bjophthalmol-2011-300539
https://www.ncbi.nlm.nih.gov/pubmed/2213... .

In Brazil, in the period from 2008 to 2016, 3,908,921 people were examined, and 149,752 trachoma cases were identified, representing a positivity percentage of 3.8%, with average variations between 2.4 and 4.9%⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Coordenação Geral de Hanseníase e Doenças em Eliminação. Informe Técnico e Operacional V Campanha Nacional de Hanseníase, Verminoses, Tracoma e Esquistossomose. Brasília: Ministério da Saúde ; 2017. 17 p..

In the state of Ceará, the results of the National Campaign for Leprosy, Vermin, Trachoma and Schistosomiasis in 2014 showed that, of the 249,822 schoolchildren aged 5 to 14 years that were examined, 8,471 were diagnosed with trachoma⁸8. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico Hanseníase, verminoses e tracoma têm cura: a experiência de uma campanha integrada [Internet]. 2016 [acessado em 12 jul. 2016]; 47(21): 1-10. Disponível em: Disponível em: http://portalms.saude.gov.br/boletins-epidemiologicos
http://portalms.saude.gov.br/boletins-ep... . In the municipality of Russas, 486 cases of the disease were detected in 8,160 students in this age group, with a positivity rate of 5.96%, and representing almost 6% of the total cases in the state⁹9. Prefeitura de Russas. Secretaria Municipal de Saúde. Planilha da Campanha Nacional de Hanseníase, Geo-helmintíases e Tracoma 2014. Russas: Prefeitura; 2014..

During the campaign period in 2014, Russas had only two doctors and an endemic control agent trained to carry out surveillance and disease control actions, that is, there was an insufficient number of professionals involved in these activities¹⁰10. Prefeitura de Russas. Secretaria Municipal de Saúde. Planilha de controle de capacitação de profissionais da atenção básica da Secretaria Municipal de Saúde de Russas. Russas: Prefeitura; 2013.. This fact, in conjunction with the epidemiological situation of trachoma among children and adolescents in the city, could have compromised treatment and treatment control in this age group. Such data justifies and highlights the importance of this research, which aimed to analyze factors associated with the treatment and control of the treatment of trachoma in schoolchildren diagnosed in the campaign carried out in 2014, in the municipality of Russas.

METHODOLOGY

A cross-sectional study was carried out from January to April 2016, in the municipality of Russas, whose estimated population, for 2015, was 75,018 inhabitants¹¹11. Ceará. Governo do Estado do Ceará. Secretaria do Planejamento e Gestão do Estado do Ceará. Instituto de Pesquisa e Estratégia Econômica do Estado do Ceará (IPECE). Perfil Básico Municipal 2015-Russas. Estimativa da População - Russas - 2012-2015. Ceará: Governo do Estado do Ceará; 2015.. The primary care network has 20 Family Health Strategy teams, nine Oral Health Teams and two Family Health Support Centers. Secondary care is composed of a Psychosocial Care Center, a Health Center, a Specialized Care Service, a Specialized Rehabilitation Center, a Diagnostic and Therapeutic Support Service, a polyclinic, a Dental Specialties Center, two hospital units, an Emergency Care Unit and a Mobile Emergency Care Service¹²12. Brasil. Ministério da Saúde. Cadastro Nacional de Estabelecimentos de Saúde. Consulta estabelecimento. Identificação: município Russas [Internet]. [acessado em 30 ago. 2018]. Disponível em: Disponível em: http://cnes.datasus.gov.br
http://cnes.datasus.gov.br... .

The sample was composed of 8,160 schoolchildren aged 5 to 14 years old, who were enrolled in the Russas public education system and examined during the National Campaign for Leprosy, Verminosis, Trachoma and Schistosomiasis that took place from January to December 2014. Of these individuals, 486 were diagnosed with trachoma, and they made up the study population. However, 96 were not located at the addresses listed nor was there information about their current place of residence in the municipality, corresponding to a loss of 20%. Thus, the study sample was made up of 390 schoolchildren. Exclusion criteria were defined as schoolchildren diagnosed with trachoma who had moved away from the municipality of Russas.

The diagnosis of trachoma is essentially clinical. It is performed through the examination of the external eye. Any individual with one or more of the following signs is confirmed to have the disease if there is: follicular trachomatous inflammation (TF); intense trachomatous inflammation (TI); conjunctival scarring trachoma (TS); TT and corneal opacification (CO)¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014..

The active search and case control forms, which are filed at the Municipal Health Secretariat, and the forms that were applied during home interviews made up the research data sources. Initially, in order to identify students with trachoma and learn about the clinical diagnosis and prescribed treatment, the active search forms that were filled in during the campaign were reviewed. In order to verify that an eye exam was performed after six months, the case control forms were analyzed. These forms recorded the control of the treatment of patients with the disease. From January to April 2016, home visits were carried out, using a form that was applied to mothers or the legal guardians, in order to collect socioeconomic and demographic information, and information regarding the primary care team’s monitoring of students.

Two dependent variables (outcomes) were defined: trachoma treatment in schoolchildren and control of trachoma treatment in schoolchildren.

The dependent variable called trachoma treatment in schoolchildren was classified as either adequate or inadequate. The variable was considered to be adequate if it was in accordance with the treatment parameters of trachoma cases, defined by the MOH as: azithromycin for 100% of the cases at a dose of 20 mg/kg of weight, in a single dose, orally, with a maximum dose of 1 gram¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014., provided that the weight and dosage were noted on the consult form. Although the MOH recommends home treatment with azithromycin for all members of a family nucleus when one or more cases of TF and/or TI are detected, in the present study, for the purpose of classifying treatment as adequate or inadequate, performing treatment was not taken into account for the other contacts.

The dependent variable called control of trachoma treatment in schoolchildren, was classified as adequate and inadequate. It was considered to be adequate if an eye exam was performed six months after the beginning of treatment, as instructed by the MOH¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014..

The independent variables were grouped into the following characteristics: demographic, socioeconomic, behavioral and primary care follow-up.

Regarding demographic and socioeconomic characteristics, the following variables were verified: age (at the time of the campaign), sex, race/color, education level, family income in minimum wages (MW), area of residence (rural or urban), housing material (clay or masonry), number of rooms and residents at home, source of water supply (public or not), garbage collection (public or not) and waste destination (public or not). The behavioral variable analyzed was the use of a towel, which was classified as individual or collective use.

As for the follow-up in primary care in the municipality, variables related to the work process of FHS professionals were collected:

The data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) software version 20.0.

To assess the association between dependent and independent variables, the odds ratio was used. Initially, a bivariate analysis was performed, and the gross OR was calculated, adopting a 95% confidence interval (95% CI), using the χ² test or Fisher’s exact test. Subsequently, a multivariate analysis was performed. It used a logistic regression to adjust for the confounding effects, including variables that presented p<0.20 in the bivariate analysis. The variables number of rooms in the house, garbage collection, and student receiving guidance from the nurse about trachoma did not enter into the bivariate analysis because they presented cells with zero information, thus not allowing for the calculation of the OR.

The multivariate model was started using the Forward Stepwise (Wald) procedure, and variables with p <0.05 remained in the final model.

The project was approved by the Research Ethics Committee of the State University of Ceará, with substantiated report number 1,386,050.

RESULTS

The treatment of trachoma was considered to be adequate in 221 students (56.7%). Regarding socioeconomic, demographic and behavioral variables, the area of residence, the source of water and the destination of waste showed an association with the outcome variable treatment of trachoma. It was found that schoolchildren from rural areas, without access to treated water and those who were living in a residence without public waste collection, were 2.14 (p=0.000), 1.67 (p = 0.014) and 3.57 (p=0.000) times more likely, respectively, to receive inadequate treatment. The variable number of rooms in a household was included in the multivariate analysis, considering p <0.20 (Table 1).

Among the variables monitored by primary care, only the variable explanation from CHA on how to avoid trachoma showed a statistically significant association with the outcome variable, treatment of trachoma (p <0.05). However, the variables, area of residence covered by CHA, the student visited UBASF in order to receive medicine, and the student received guidance from nurses on trachoma, were included in the multivariate analysis because they presented p <0.20 (Table 2).

With regard to treatment control, a total of 83 students (21.3%) did it outside the scheduled date, and 284 (72.8%) did not do it. This totals 367 (94.1%) students with treatment control that is considered to be inadequate. Thus, the treatment control was pointed out to be adequate in only 23 students (5.9%), for being carried out in the period recommended by the MOH (Table 3).

Regarding socioeconomic, demographic and behavioral factors, the variables, family income (p = 0.004), and area of residence (p = 0.000) showed a statistically significant association with the variable treatment control outcome, revealing that schoolchildren with a family income below one minimum wage and living in the countryside were 3.99 and 14.20 times more likely, respectively, to receive inadequate treatment control. The variables age, race/color and number of residents in the household were included in the multivariate analysis because they had p <0.20 (Table 3).

The variables related to the primary health care CHA follow-up explained how to avoid trachoma and ACE clarified how to avoid trachoma had a statistically significant association with the treatment control outcome variable (p <0.05). The variable, student was examined by a doctor at UBASF, was included in the multivariate analysis because it had p <0.20. Approximately 30% of the families did not receive guidance from the CHA on how to avoid trachoma, and only 15.1% of the students were examined by the doctor at UBASF (Table 4).

Table 5 expresses the results of the multivariate analysis, verifying that, for the outcome variable treatment of trachoma, only the variables, area of residence, and destination of waste, remained in the multivariate model, showing that students from rural areas and living in homes without a public sewage system were 1.77 and 2.79 times more likely, respectively, to receive inadequate treatment.

Regarding the outcome variable, trachoma treatment control, the following variables remained in the multivariate model: area of residence, income, and student examined by a doctor at UBASF, noting that those in the rural area, coming from families with an income below one minimum wage, and those who were not examined by a doctor were 21.10, 5.33 and 4.99 times more likely, respectively, to perform inadequate treatment control.

DISCUSSION

In the present study, most students were given medicine, but in almost half of them, the treatment was considered inadequate, due to the fact that the medication administered was not registered in the campaign’s attendance form.

The correct treatment of trachoma cases is important both at the individual level, for curing infections, and at the population level, considering that the objective is to interrupt the chain of transmission of the disease and reduce the circulation of the etiological agent in the community, decreasing the frequency of reinfections and the severity of cases¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014..

Studies carried out in Brazil revealed the presence of the disease in much of the country, especially in areas with the worst quality of life indicators, where the positivity percentage remains above 10%, suggesting an epidemiological situation that can evolve to cases of blindness⁷7. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Coordenação Geral de Hanseníase e Doenças em Eliminação. Informe Técnico e Operacional V Campanha Nacional de Hanseníase, Verminoses, Tracoma e Esquistossomose. Brasília: Ministério da Saúde ; 2017. 17 p..

Families in rural areas find it difficult to travel to UBASF due to lack of access to transportation and the geographical distance, which compromises the use of this health service. The influence of geographic factors on access to and use of health services of families living in rural areas has been described by several authors¹³13. Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad Saúde Pública [Internet]. 2018 [acessado em 28 ago. 2018]; 34(6): e00213816. Disponível em: http://dx.doi.org/10.1590/0102-311x00213816
https://doi.org/http://dx.doi.org/10.159... ^,1414. Unglert CVS, Rosenburg CP, Junqueira CB. Acesso aos serviços de saúde: uma abordagem de geografia em saúde pública. Rev Saúde Pública 1987; 21(5): 439-46., showing that great geographical distances, transport difficulties and poverty concentration represent important barriers¹⁵15. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saúde Pública 2007; 23(10): 2490-502..

The association of the variable treatment of trachoma with living in homes without access to the public sewage system suggests an unfavorable socioeconomic situation for families, which limits their search for health facilities. The homes of schoolchildren diagnosed with trachoma in Russas mostly use septic tanks for feces, and the public system is responsible for a small percentage of the collection of these wastes. The situation is even more serious in rural areas. Improving access to sanitation and water are recommendations present in the SAFE strategy, to reach the goal of eliminating this disease¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014.. In a study carried out in Pelotas, RS, the authors found a predominance in the lack of access to health services among people with lower economic conditions¹⁶16. Nunes BP, Thumé E, Tomasi E, Duro SMS, Facchini LA. Desigualdades socioeconômicas no acesso e qualidade da atenção nos serviços de saúde. Rev Saúde Pública 2014; 48(6): 968-76. http://dx.doi.org/10.1590/S0034-8910.2014048005388
https://doi.org/http://dx.doi.org/10.159... .

With regard to primary health care actions, although most students lived in an area covered by a CHA, approximately one third of the families did not receive guidance on disease prevention by this professional. It is worth noting the high percentage of students who were not examined by the doctor at UBASF or guided by the ACE on how to avoid trachoma. These findings can be explained by the fact that there is only one CHA in the municipality that is responsible for evaluating students during the campaign. They did not have time for home visits for all those diagnosed with the disease, and only two doctors were trained to assist these patients.

Inequality in the distribution of human resources in health, especially doctors, persists as a serious problem, contributing to inequity in access to health services¹⁷17. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg em Saúde para Debate 2009; (44): 13-24., especially in rural or underserved regions¹⁸18. Oliveira FP, Vanni T, Pinto HA, Santos JTR, Figueiredo AM, Araújo SQ, et al. Mais Médicos: um programa brasileiro em uma perspectiva internacional. Interface 2015; 19(54): 623-34. http://dx.doi.org/10.1590/1807-57622014.1142
https://doi.org/http://dx.doi.org/10.159... , with a shortage of doctors in primary care and a concentration of specialists in the private sector¹⁹19. Oliveira APC, Gabriel M, Dal Poz MR, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Ciên Saúde Coletiva 2017; 22(4): 1165-80. http://dx.doi.org/10.1590/1413-81232017224.31382016
https://doi.org/http://dx.doi.org/10.159... .

Health education activities with information on treatment, forms of prevention and control of trachoma, especially by the primary care team, are some of the main strategies for the elimination of the disease⁵5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Coordenação Geral de Hanseníase e Doenças em Eliminação. Guia prático para operacionalização da Campanha Nacional de Hanseníase, Verminoses, Tracoma e Esquistossomose 2016. Brasília: Ministério da Saúde ; 2016. 50 p.. In the present research, during the interviews at home, the causes most cited by mothers or guardians for not undergoing treatment were: lack of information from FHS professionals about the need to use the medication, medication not being delivered, and the adolescent’s refusal to take the medication.

Regarding the control of trachoma treatment, a minimum percentage was considered adequate. Among the students examined during treatment control, the fact that in more than half, the inflammatory signs of the disease persisted, the treatment scheme was restarted, and home contacts were also treated. Repeated episodes of active trachoma will result in scarring of the eyelids, progressing to TT, which, if left untreated, can lead to OC, causing decreased visual acuity and even blindness²⁰20. World Health Organization. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report on elimination of trachoma, 2017. Wkly Epidemiol Rec [Internet] 2018 [acessado em 30 ago. 2018]; 93(26): 369-80. Disponível em: Disponível em: http://www.who.int/wer
http://www.who.int/wer... .

The association of the dependent variable treatment control with the variables, family income below one minimum wage, rural residence area and child not having been examined by a doctor, reinforces the influence of socioeconomic conditions on access and use of health services. Authors show the effects of poverty on the lack of information and health care²¹21. Ketema K, Tiruneh M, Woldeyohannes D, Muluye D. Active trachoma and associated risk factors among children in Baso Liben District of East Gojjam, Ethiopia. BMC Public Health [Internet]. 2012 [acessado em 21 jun. 2015]; 12: 1105. Disponível em: Disponível em: http://www.biomedcentral.com/1471-2458/12/1105 . http://doi.org/10.1186/1471-2458-12-1105
http://www.biomedcentral.com/1471-2458/1... .

Health education interventions and improvements in housing, access to water, the proper destination of waste and the quality of life of the population, as well as body care, personal and family hygiene, are the most effective preventive actions related to disease transmission and control¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Manual de vigilância do tracoma e sua eliminação como causa de cegueira. 2ª ed. Brasília: Ministério da Saúde; 2014.^,2222. Mahande MJ, Mazigo HD, Kweka EJ. Association between water related factors and active trachoma in Hai district, Northern Tanzania. Infect Dis Poverty [Internet]. 2012 [acessado em 21 jun. 2016]; 1: 10. Disponível em: Disponível em: http://www.idpjournal.com/content/1/1/10 . http://doi.org/10.1186/2049-9957-1-10
http://www.idpjournal.com/content/1/1/10... .

The study’s limitations include distance and difficulty in accessing some locations in rural areas, in addition to the affective bond between the members of the health team and the interviewed families, which may have contributed to an underestimate or overestimate of the negative responses and statements regarding primary care monitoring.

CONCLUSION

The inadequate treatment of trachoma was associated with residence in a rural area, and the destination of waste in septic tanks/open areas, while the factors associated with inadequate treatment control were rural residence, income below one minimum wage, and the student not being examined by the doctor.

The high percentage of treatment and treatment control considered inadequate allows us to conclude that the actions of the trachoma control program in schoolchildren in the municipality of Russas are not being carried out as recommended by the Ministry of Health.

Health promotion and disease prevention activities were not accessible for the entire community, indicating the need for greater involvement in health education actions by primary care professionals, especially the CHAs, who work directly in homes. They aim to achieve comprehensive care and the effective integration between primary care and health surveillance in the municipality.

References

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History