Abstract

Objective

To describe the process of Endemic Disease Control Worker (EDCW) integration into the Family Health Strategy.

Methods

This was a descriptive cross-sectional study. Data were collected through a self-administered semi-structured questionnaire, from February to May 2017, in four Family Health centers in the urban region of Campo Grande, Mato Grosso do Sul, Brazil.

Results

57 Community Health Agents (CHW) and eight EDCWs participated. All participants reported providing guidance to property dwellers and 58 carried out mechanical vector control during the inspection of properties, in order to avoid and eliminate possible Aedes aegypti breeding sites. With regard to EDCW integration in the Family Health Strategy, 18 participants highlighted teamwork as a positive aspect; while 15 highlighted lack of autonomy to undertake legal interventions as a negative aspect.

Conclusion

EDCW integration in the Family Health Strategy is feasible, however, adjustments need to be made to optimize activities within the perspective of shared work in the same territorial area.

Primary Health Care; Family Health; Dengue; Aedes; Vector Control

Introduction

Dengue is the arbovirus that most affects humankind and is considered to be an endemic disease in over 100 countries. It is estimated that 390,000,000 individuals are at risk of infection.(¹1. Li Z, Liu T, Zhu G, Lin H, Zhang Y, He J, et al. Dengue Baidu Search Index data can improve the prediction of local dengue epidemic: a case study in Guangzhou, China. PLoS Negl Trop Dis [Internet]. 2017 Mar [cited 2020 Jul 21];11(3):e0005354. Available from: https://doi.org/10.1371/journal.pntd.0005354
https://doi.org/10.1371/journal.pntd.000... ) In Brazil, the growing number of severe cases and deaths makes this health condition even more significant.(³3. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Dengue: diagnóstico e manejo clínico: adulto e criança [Internet]. 5. ed. Brasília: Ministério da Saúde; 2016 [citado 2020 jul 21]. 58 p. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2016/janeiro/14/dengue-manejo-adulto-crianca-5d.pdf
https://portalarquivos2.saude.gov.br/ima... )

Between 2000 and 2010 in the state of Mato Grosso do Sul and its capital city, Campo Grande, dengue incidence followed the pattern found for the country’s Midwest region and for Brazil as a whole, involving cycles of high transmissibility. In 2010, the incidence rate for the state of Mato Grosso do Sul was 1,167.8 cases per 100,000 inhabitants, while the rate for Campo Grande city was 3,952.5 cases per 100,000 inhab.(⁵5. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Sistema nacional de vigilância em saúde: relatório de situação: Mato Grosso do Sul [Internet]. 5. ed. Brasília: Ministério da Saúde; 2011 [citado 2020 jul 21]. 36 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/sistema_nacional_vigilancia_saude_mt_5ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... )In the years that followed, the dengue epidemics that occurred had a well-defined pattern involving cycles every three years. In 2013, when infection was at its highest, the state recorded 3,017.9 cases per 100,000 inhab., while its capital city recorded 5,605.0 cases per 100,000 inhab. In 2016, the state recorded 1,671.3 cases per 100,000 inhab. and the capital recorded 3,293.93 cases per 100,000 inhab.(⁶6. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue, febre de chikungunya e febre pelo vírus Zika até a Semana Epidemiológica 23, 2016. Bol Epidemiol [Internet]. 2016 [citado 2020 jul 21];47(28). Disponível em: http://www.saude.gov.br/images/pdf/2016/julho/15/2016-boletim-epi-n28-dengue-chik-zika-se23.pdf
http://www.saude.gov.br/images/pdf/2016/... )

The National Dengue Control Program was created in 2002 as a strategy to address this endemic disease. One of its components was the integration of dengue control actions performed by endemic disease control workers (EDCW) with the activities of community health workers (CHW) in the Family Health Strategy teams.(⁸8. Ministério da Saúde (BR). Fundação Nacional de Saúde. Programa nacional de controle da dengue [Internet]. Brasília: Ministério da Saúde; 2002 [citado 2020 jul 21]. 32 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pncd_2002.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ) In 2009, the Ministry of Health alerted as to the need to reorganize work processes and define the roles and responsibilities of these health workers. The following year, Health Ministry Ordinance No. 1007, dated May 4^th 2010, reaffirmed EDCW integration in Primary Health Care.(⁹9. Brasil. Ministério da Saúde. Portaria MS/GM nº 1.007, de 04 de maio de 2010. Define critérios para regulamentar a incorporação do Agente de Combate às Endemias - ACE, ou dos agentes que desempenham essas atividades, mas com outras denominações, na atenção primária à saúde para fortalecer as ações de vigilância em saúde junto às equipes de Saúde da Família [Internet]. Diário Oficial da União, Brasília (DF), 2010 maio 5 [citado 2020 jul 21];Seção I:36. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt1007_04_05_2010.html
http://bvsms.saude.gov.br/bvs/saudelegis... )

In Campo Grande, these recommendations were put into place in 2011, under the coordination of the Health Care and Health Surveillance Directorates. The reference for this process was a publication produced by the municipal government entitled ‘Instructional Booklet – EDCW/CHW Integration in the Family Health Strategy’. It established the work process and the attributions of EDCWs and CHWs working in the same territorial area.(¹¹11. Secretaria Municipal de Saúde de Campo Grande (MS). Resolução nº 362, de 23 de janeiro de 2018. Nota técnica para o processo de trabalho da integração do ACE/ASP na ESF/EACS no âmbito da Secretaria Municipal de Saúde e dá outras providências [Internet]. Diogrande, Campo Grande (MS), 2018 jan 24 [citado 2020 jul 21];Seção I:21. Disponível em: https://www.campograndenews.com.br/uploads/noticias/2020/03/10/82k03xwajb3o.pdf
https://www.campograndenews.com.br/uploa... )

The objective of this study was to describe the process of integrating endemic disease control workers – EDCW – into the Family Health Strategy, in Campo Grande city, capital of the state of Mato Grosso do Sul, Brazil, in 2017.

Methods

This was a descriptive cross-sectional study conducted between February and May 2017 at four Family Health centers in urban areas of Campo Grande, MS.

The Family Health centers were selected by convenience, taking one from each of the municipality’s four Health Districts and ensuring that their teams had sufficient length of experience with EDCW integration. Of the four Family Health centers, three were chosen because they were the first to take part in the pilot project in 2011 and the fourth took part with effect from 2012.

EDCWs at work at the time of data collection and who had worked for more than six months at the Family Health center were invited to take part in the study.

A self-administered semi-structured questionnaire was used to collect the data (included as supplementary material to this manuscript), developed based on the Health Ministry’s Instructional Booklet, containing 24 questions divided into three topics: (i) work process organization; (ii) vector control actions; (iii) job responsibilities.

The Instructional Booklet proposes use of two work tools: (i) the checklist, a specific CHW tool, used during household visits to record the main problems found when inspecting the property and serving to inform CWH instructional and educational actions with families (living in the visited household) and to notify them as to the need to eliminate uncovered water recipients and rubbish;(¹²12. Cesariano MB, Dibo MR, Ianni AMZ, Vicentini ME, Ferraz AA, Neto FC. A difícil interface controle de vetores-atenção básica: inserção dos agentes de controle de vetores da dengue junto às equipes de saúde das unidades básicas no município de São José do Rio Preto. Saúde Soc [Internet]. 2014 set [citado 2017 set 19];23(3):1018-32. Disponível em: http://dx.doi.org/10.1590/S0104-12902014000300023
http://dx.doi.org/10.1590/S0104-12902014... ) and (ii) the Rapid Aedes aegypti Rate Estimator (LIRAa in Portuguese), an instrument for estimating the degree of infestation and distribution of the vector mosquito in the household environment.(¹³13. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Levantamento rápido de índices para Aedes Aegypti (LIRAa) para vigilância entomológica do Aedes aegypti no Brasil: metodologia para avaliação dos índices de Breteau e Predial e tipo de recipientes [Internet]. Brasília: Ministério da Saúde; 2013 [citado 2020 jul 21]. 84 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_liraa_2013.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... )

Data collection was scheduled in advance with the manager of the Family Health center according to the availability of the health workers.

Microsoft Excel^® 2010 was used to support data organization and analysis, involving tabulation of absolute and relative frequencies of CHW/EDCW use of the different work tools, their participation in team meetings, supervision of their activities and the person responsible for supervision, and the importance of integrating the two categories of health workers as perceived by them.

The study project was approved by the Federal University of Mato Grosso do Sul Research Ethics Committee: Certificate of Submission for Ethical Appraisal No. 62362716.7.0000.0021, issued on January 25^th 2017. All participants signed a Free and Informed Consent form.

Results

In all, the 12 teams working at the four Family Health centers were comprised of a total of 75 CHWs and 8 EDCWs. Eighteen 18 CHWs were considered to be losses: 5 because of annual leave and 13 because of sick leave. As such, a total of 65 health workers took part (57 CHWs and 8 EDCWs).

With regard to work tools (Table 1), when asked about what they did when items on the checklist had unsatisfactory results when inspecting properties, the majority of the CHWs (42/57) informed that they gave guidance to the property dweller and 40/57 stated that they carried out mechanical vector control at the site. Over half the CHWs (33/57) did not use the Rapid Aedes aegypti Rate Estimator for planning their actions, justifying this by stating that the results were rarely presented and discussed in team meetings, while the majority of EDCWs (7/8) stated they used it routinely. Moreover, the CHWs acknowledged that the Rapid Aedes aegypti Rate Estimator results can influence the activities they carry out, by giving visibility to places where risk is greater (21/57) and intensifying visits (15/57).

Table 2 illustrates the results with regard to work process. All 65 participants provided guidance to property dwellers about how to avoid and eliminate possible Aedes aegypti breeding sites, 62/65 gave guidance on dengue signs and symptoms and 58/65 carried out mechanical vector control. Weekly team meetings were reported by 53/65 workers. All 8 EDCWs and 54/57 CHWs stated that their dengue control activities were supervised. Of these, 30/57 CHWs reported that supervision was done by the team nurse, 2/57 CHWs and 7/8 EDCWs, by the area supervisor, and just one (1/8) EDCW and 25/57 CHWs said that supervision was shared by the nurse and the area supervisor.

Seven (7/8) EDCWs and 29/57 CHWs considered that EDCW integration into Family Health Strategy teams was very important, and that positive points of integration were (i) team work, for 7/8 EDCWs and 23/57CHWs, and (ii) prioritization of Family Health Strategy actions, highlighted by 8/57 CHWs. With regard to negative factors, lack of autonomy to perform legal interventions was predominant among 6/8 EDCWs; while among CHWs, 14/57 reported absence of intersectoral workflow, and 8/57 reported accumulation of work tasks (Table 3).

Discussion

This study described the process of EDCW integration in the Family Health Strategy, according to (i) work process organization, (ii) vector control actions and (iii) job responsibilities. All participants gave guidance to property dwellers about possible vector breeding sites and two thirds of them gave guidance about dengue signs and symptoms. The Rapid Aedes aegypti Rate Estimator was used by a minority of the CHW and by the majority of the EDCWs. EDCW integration in the Family Health Strategy was perceived as being very important for the majority of the EDCWs and for around half the CHWs.

EDCW integration in the Family Health Strategy, as determined by the Ministry of Health,(⁶6. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue, febre de chikungunya e febre pelo vírus Zika até a Semana Epidemiológica 23, 2016. Bol Epidemiol [Internet]. 2016 [citado 2020 jul 21];47(28). Disponível em: http://www.saude.gov.br/images/pdf/2016/julho/15/2016-boletim-epi-n28-dengue-chik-zika-se23.pdf
http://www.saude.gov.br/images/pdf/2016/... ) was supported in Campo Grande by the ‘Instructional Booklet – EDCW/CHW Integration in the Family Health Strategy’, which also recommends the use of work instruments such as the checklist, this being a specific CHW tool. A similar instrument was developed in São José do Rio Preto, São Paulo, known as the ‘property record’, which enabled monitoring of the situation found at the property, by means of assessing needs for changes in the proprietor’s behavior in relation to the points raised in the previous visit.(¹⁴14. Ferreira AD, Vieira ER, Neves FM. Integração do ACE na ESF e EACS no município de Campo Grande: coletânea de instrumentos norteadores para Estratégia de Saúde da Família campo-grandense. Campo Grande: Secretaria Municipal de Saúde Pública; 2012. p. 1-13)

The Rapid Aedes aegypti Rate Estimator was little used by the CHWs in this study, given the low feedback on its results to the rest of the team. Socializing results is important for obtaining support in actions intended to address endemic diseases in each municipality, and also to engage support of the population and sectors other than the Health sector.(¹³13. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Levantamento rápido de índices para Aedes Aegypti (LIRAa) para vigilância entomológica do Aedes aegypti no Brasil: metodologia para avaliação dos índices de Breteau e Predial e tipo de recipientes [Internet]. Brasília: Ministério da Saúde; 2013 [citado 2020 jul 21]. 84 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_liraa_2013.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... )

The scope of the responsibilities recommended in the Instructional Booklet provides that the health center manager should ensure meetings and encourage EDCW participation in these discussion spaces.(¹⁴14. Ferreira AD, Vieira ER, Neves FM. Integração do ACE na ESF e EACS no município de Campo Grande: coletânea de instrumentos norteadores para Estratégia de Saúde da Família campo-grandense. Campo Grande: Secretaria Municipal de Saúde Pública; 2012. p. 1-13) This study found that meetings were held weekly and that nurses, CHWs and EDCWs participated most in them. It should be noted that the Ministry of Health recommends that all health workers comprising the Family Health Strategy teams should take part.(¹⁵15. Brasil. Ministério da Saúde. Portaria de consolidação MS/GM nº 2, anexo XXII de 28 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS) [Internet]. Diário Oficial União, Brasília (DF), 2017 set 22 [citado 2020 jul 21];Seção I:68. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prc0002_03_10_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis... )

There were few reports of shared supervision in this study. Supervision by nurses of CWH actions in relation to health surveillance and supervision by the area supervisor of EDCW actions in relation to vector and zoonosis control, strengthens integrated actions within the array of Primary Care activities.(⁹9. Brasil. Ministério da Saúde. Portaria MS/GM nº 1.007, de 04 de maio de 2010. Define critérios para regulamentar a incorporação do Agente de Combate às Endemias - ACE, ou dos agentes que desempenham essas atividades, mas com outras denominações, na atenção primária à saúde para fortalecer as ações de vigilância em saúde junto às equipes de Saúde da Família [Internet]. Diário Oficial da União, Brasília (DF), 2010 maio 5 [citado 2020 jul 21];Seção I:36. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt1007_04_05_2010.html
http://bvsms.saude.gov.br/bvs/saudelegis... ) Moreover, supervision of EDCW activities by university-qualified Family Health Strategy workers facilitates their integration as team members.(¹⁶16. Pessoa JPM, Oliveira ESF, Lemos CLS, Teixeira RAG. Integração e articulação intersetorial no controle da dengue: a percepção dos agentes de combate de endemias. Indagatio Didactica [Internet]. 2013 ago [citado 2018 out 9];5(2):490496. Disponível em: https://proa.ua.pt/index.php/id/article/view/4390
https://proa.ua.pt/index.php/id/article/... )

Identification of factors that hinder or assist the process of EDCW integration in dengue prevention and control activities within the Family Health Strategy contributes to cooperation and coordination, as well as assisting local management in evaluating and analyzing the impacts of their actions.(¹⁷17. Pessoa JPM, Oliveira ESF, Teixeira RAG, Lemos CLS, Barros NF. Controle da dengue: os consensos produzidos por Agentes de Combate às Endemias e Agentes Comunitários de Saúde sobre as ações integradas. Ciênc Saúde Coletiva [Internet]. 2016 ago [citado 2016 set 5];21(8):2329-38. Disponível em: http://dx.doi.org/10.1590/1413-81232015218.05462016
http://dx.doi.org/10.1590/1413-812320152... )With regard to the positive aspects, the reports regarding team work, information sharing, immediate case notification and prioritization of Family Health Strategy actions suggest the relevance of integrating EDCWs into the Family Health Strategy teams for dengue control actions. As for the negative aspects, accumulation of work tasks by CHWs and absence of intersectoral workflow in terms of effective integration as perceived by some CHWs, and absence of autonomy to carry out legal interventions as reported by both EDCWs and CHWs, can cast doubt on the work carried out by community health workers as perceived by the families under their responsibility.

Although this study did not examine the participation of other health worker categories – nurses, area supervisors, local managers etc. –, its findings can provide a basis for further studies and thus expand the discussion on integration between endemic disease control workers and community health workers.

References

Supplmentary Material – Data collection questionnaire

APPENDIX A – DATA COLLECTION QUESTIONNAIRE

This is a Master’s Degree study. Your participation is very important, since the result of this study will guide actions related to the work process and single territory integrated surveillance actions. Read the questions carefully and choose the alternative that best describes your daily work.

Reading and signing of the Free and Informed Consent form.

Guidance on filling in the questionnaire.

COLLECTION INSTRUMENT

DATE: ____/____/____ Health District: _____________________

Identification/Family Health Center: _________________________________________________

1. Professional characterization:

( ) Community Health Worker (CHW) ( ) Endemic Disease Control Worker (EDCW)

2. How long have you been working as a CHW/EDCW?

___(years)/___(months)

3. Did you receive training when CHW/EDCW were integrated at your health center?

( ) Yes ( ) No

4. How often do you receive training/updating about CHW/EDCW integration?

( ) Never ( ) Rarely ( ) Sometimes ( ) Frequently ( ) Always

5. What topics are addressed in the trainings? (you may choose more than one answer).

( ) notions about dengue ( ) vector biology ( ) mechanical vector control

( ) type of breeding site / Rapid Aedes aegypti Rate Estimator

( ) household visits ( ) there is no training.

6. Do you use the Checklist?

( ) Yes ( ) No ( ) Sometimes

Justify your answer: ______________________________________

7. When making a household visit (HV), if a Checklist item is unsatisfactory, what do you do? (you may choose more than one answer).

( ) Mechanical vector elimination ( ) Dweller guidance ( ) Refer to the nurse

( ) Request chemical treatment ( ) Request health surveillance measures

( ) Carry out the HV without any need for additional actions

( ) I do not use the Checklist.

8. How often are team meetings held?

( ) weekly ( ) fortnightly ( ) monthly ( ) rarely ( ) never

9. Who takes part in the team meeting? (you may choose more than one answer).

( ) Nursing technician ( ) Doctor ( ) CWH ( ) EDCW ( ) Area supervisor

( ) Nurse ( ) Dentist ( ) Oral health auxiliary ( ) Manager ( ) Other health workers

10. Do you use the Rapid Aedes aegypti Rate Estimator as a tool for planning actions in your territory?

( ) Yes ( ) No

Justify your answer: ______________________________________

11. Are the Rapid Aedes aegypti Rate Estimator results presented in team meetings?

( ) Never ( ) Rarely ( ) Sometimes ( ) Frequently ( ) Always

12. Do you believe that the Rapid Aedes aegypti Rate Estimator results can influence the activities undertaken by you in your territory?

( ) Yes ( ) No

Justify your answer: ______________________________________

13. Do you use the dynamic map?

( ) Never ( ) Rarely ( ) Sometimes ( ) Frequently ( ) Always

14. In your opinion, what is the importance of the dynamic map?

__________________________________________________________________________

__________________________________________________________________________

15. Are meetings held for debriefing on the previous day’s activities? (Meetings together with the nurse and area supervisor to exchange information).

( ) Yes ( ) No

Justify your answer: ______________________________________

16. Do you receive in-field supervision on vector actions?

( ) Yes ( ) No

17. Who supervises you? (you may choose more than one answer).

( ) Nurse ( ) Supervisor ( ) Manager ( ) Coordinator ( ) I do not have supervision

( ) I don’t know

18. With regard to household visits, what is done if a micro area (MA) is discovered? (you may choose more than one answer).

( ) MA rotation ( ) MA joint efforts ( ) Visits are not made

19. In the event of shut up property and/or when the dweller is not at home, what do you do?

__________________________________________________________________________

20. During household visits (HV), which of these activities do you carry out? (you may choose more than one answer).

( ) Inspect the rooms in the house, together with the dweller, to see if there are Aedes aegypti and mosquito breeding sites.

( ) Inspect the rooms in the house, together with the dweller, to see if there are Aedes aegypti and mosquito breeding sites, carrying out mechanical vector control.

( ) Inspect the rooms in the house, together with the dweller, to see if there are Aedes aegypti and mosquito breeding sites, collecting lava for subsequent laboratory tests.

( ) Carry out mechanical vector control.

( ) Give guidance to the dweller on how to avoid and eliminate places that might be at risk of becoming Aedes aegypti breeding sites.

( ) Let your immediate supervisor know about the presence of breeding sites in the household for interventions to be made.

( ) Visit households informing dwellers about the disease – symptoms and risks – and about the causative agent.

( ) Refer suspected cases to the Health Center.

( ) Ask the dweller about the presence of possible breeding sites without needing to inspect the household or make a record of the visit.

( ) Investigate complaints made by neighbors about possible breeding sites in the micro area.

( ) Update the properties and strategic points register.

( ) Identify breeding sites and apply larvicide, when indicated, as a complementary measure to mechanical vector control.

( ) Carry out community education and mobilization actions for dengue control, in your catchment area.

21. How important is integration for you?

( ) Very important ( ) Important ( ) Not very important

Justify your answer: ____________________________________________________________

___________________________________________________

22. How do you feel in relation to CHW/EDCW integration?

( ) Satisfied ( ) Dissatisfied

23. Describe the positive and negative points of CHW/EDCW integration:

_____________________________________________________________________________

___________________________________________________

24. How do you rate your knowledge about the CHW/EDCW integration project?

( ) Very good ( ) Good ( ) Poor ( ) I don’t know

Publication Dates

History