Abstract

Introduction

The Family Health Strategy (FHS) has taken on an essential role for Primary Care through its amplification, qualification and consolidation, enshrined in the Health Agreement 2006 (Conill, 2008CONILL, E. M. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S7-S27, 2008. Suplemento.; Brasil, 2006BRASIL. Ministério da Saúde. Secretaria Executiva. Departamento de Apoio à Descentralização. Coordenação-Geral de Apoio à Gestão Descentralizada. Diretrizes operacionais dos Pactos pela Vida, em Defesa do SUS e de Gestão. Brasília, DF, 2006. (Série A. Normas e Manuais Técnicos). Disponível em: <http://189.28.128.100/dab/docs/publicacoes/pactos/pactos_vol1.pdf>. Acesso em: 13 fev. 2011.
http://189.28.128.100/dab/docs/publicaco... ). Ordinance no 2,488, of October 2011, emphasizes one of the objectives of the strategy, that of "systematically evaluating and monitoring the results achieved, as part of the planning and programming process" (Brasil, 2011BRASIL. Portaria n° 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 21 de outubro de 2011. Seção 1, p. 48-55.; Sousa; Hamann, 2009SOUSA, M. F.; HAMANN, E. M. Programa Saúde da Família no Brasil: uma agenda incompleta? Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1325-1335, 2009. Suplemento.).

Among the most important FHS principles, comprehensiveness guarantees that the Family Health Team meets not only the biological but also the socio-cultural demands of the population assigned to them (Takeda, 2004TAKEDA, S. A Organização de Serviços de Atenção Primária à Saúde. In: DUNCAN, B. B.; SCHMIDT, M. I.; GIUGLIANI, E. R. J. Medicina ambulatorial: condutas de atenção primária baseadas em evidências. Porto Alegre: Artmed, 2004. p. 76-87.). To achieve comprehensiveness, the population of the territory needs to be properly allocated in relation to staff (Conill, 2008CONILL, E. M. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S7-S27, 2008. Suplemento.). Otherwise, the team will encounter difficulties in their activities promoting health, prevention, treatment, rehabilitation and maintaining health, and thus fail to completely fulfill their role (Conill, 2008CONILL, E. M. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S7-S27, 2008. Suplemento.; Facchini et al., 2006FACCHINI, L. A. et al. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 11, p. 669-681, 2006.).

Moreover, comprehensiveness and longitudinality depend on the bonds created and the responsibilities accepted between the teams and the populations assigned to them, also guaranteeing coordination of care and of continuous health care activities (Brasil, 2011BRASIL. Portaria n° 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 21 de outubro de 2011. Seção 1, p. 48-55.; Sousa; Hamann, 2009SOUSA, M. F.; HAMANN, E. M. Programa Saúde da Família no Brasil: uma agenda incompleta? Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1325-1335, 2009. Suplemento.). Bonds are necessary for the light technology used by the teams (Coelho; Jorge, 2009COELHO, M. O.; JORGE, M. S. B. Tecnologia das relações como dispositivo do atendimento humanizado na atenção básica à saúde na perspectiva do acesso, do acolhimento e do vínculo. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1523-1531, 2009. Suplemento.).

The territorialization process is an essential form of recognizing resources, permitting interactions that promote the population's own support network and recognizing already established needs (Sousa; Hamann, 2009SOUSA, M. F.; HAMANN, E. M. Programa Saúde da Família no Brasil: uma agenda incompleta? Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1325-1335, 2009. Suplemento.; Viana et al., 2006VIANA, A. L. D. et al. Modelos de atenção básica nos grandes municípios paulistas: efetividade, eficácia, sustentabilidade e governabilidade. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, n. 3, p. 577-606, 2006.).

The referral and counter referral system is also essential in guaranteeing comprehensiveness for constructing health care networks and for minimizing fragmentation of health care between the health care systems various levels of complexity (the authors…, 2012OS AUTORES respondem: quinze anos de uma agenda em construção: diálogos sobre o PSF no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1343-1345, 2012. Suplemento 1. Disponível em: <http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1413-81232009000800006&lng=pt&nrm=iso>. Acesso em: 10 fev. 2012.
http://www.scielosp.org/scielo.php?scrip... ).

Finally, comprehensiveness also depends on the Family Health Strategy professionals' satisfaction and ability to resolve problems, which can be influenced by the physical structure of the health care centers (Facchini et al., 2006FACCHINI, L. A. et al. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 11, p. 669-681, 2006.). This factor should therefore be considered when evaluating implementation and qualification of the FHS.

In many municipalities, Primary Care is organized into health care units with traditional teams, typical Family Health teams and expanded Family Health teams. According to ordinance 2.488/2011, the Primary Care Department recognized these combinations of teams in its organization and running, offering different forms of municipal primary network financing (Brasil, 2011BRASIL. Portaria n° 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 21 de outubro de 2011. Seção 1, p. 48-55.).

If they are to be truly effective structures, able to develop stages to survey needs, diagnose and program activities for the population assigned to them, more needs to be known about the process of implementing and qualifying these primary health care models.

The aim of this study is to compare results obtained from applying the method and the Questionnaire of Shared Diagnosis in Primary Care (QD-CAB) in the areas concerning comprehensiveness, between typical and expanded Family Health teams in a town in São Paulo state.

Material and Methods

This study was an epidemiological survey.

The method and the Questionnaire of Shared Diagnosis in Primary Care (QDCAB) was used. It was devised and described by Pinto in shared diagnosis in family health care teams (Pinto, 2008PINTO, C. A. G. Diagnóstico compartilhado no trabalho das equipes de saúde da família. In: CAMPOS, G. W. S.; GUERRERO, A. V. P. (Org.). Manual de práticas de atenção básica: saúde ampliada e compartilhada. São Paulo: Aderaldo & Rothschild, 2008. p. 298-322.) in which the teams are asked to conduct self-evaluation. The method of applying the questionnaire to the team allows for group discussion and collective self-analysis and management.

The results obtained from applying the QDCAB in typical and expanded Family Health teams were compared. The typical Family Health teams had a GP, whereas the expanded teams had a GP, pediatrician and gynecologist, working with two or more teams. Thus, meetings were set up with member of the family health teams in the municipality of Ribeirão Preto which agreed to take part in the study. The QDCAB was applied in these meetings. In this study, the QDCAB items analyzed were as follows: the teams' relationships with the population assigned to them, knowledge of the territory, relationships with the specialists, health promoting activities and infrastructure conditions. These items were selected because of their importance in achieving comprehensiveness.

After applying the QDCAB to the Family Health teams, the responses of the typical and expanded teams were compared using the Wilcoxon-Mann-Whitney test, used for comparing two samples extracted from independent populations (Hart, 2001HART, A. MannWhitney test is not just a test of medians: differences in spread can be important. BMJ: British Medical Journal, London, v. 323, n. 7309, p. 391-393, 2001.). The test makes it possible to evaluate whether there are significant differences in the distribution of responses between the two models of Family Health teams. The SAS System was used in this analysis.

The study was approved by the Research Ethics Committee of the Clinical Hospital belonging to the Faculty of Medicine, Ribeirão Preto - USP (Process HCRP no 8.788/2010).

Results

The data were collected between May 2011 and November 2011. Twenty Family Health teams were interviewed, six of which were expanded Family Health teams and 14 of which were typical Family Health teams, with 137 Family Health Strategy professionals participating.

Of the 137 professionals, 34 were from the expanded teams and 103 from typical teams. Table 1 shows the distribution of professionals interviewed according to type of Family Health team.

Teams' relationship with the population assigned to them and knowledge of the territory

Chart 1 shows measures of position and of variability (mean, standard deviation and median) for the responses to the questions on the team's relationship with the population assigned to them and their knowledge of the territory.

There were no differences in the teams' evaluations concerning efforts made in establishing bonds and contract in the way they interacted with the families in the area covered (0.3614). Both models of teams allocated high marks to this question.

The way in which typical style teams establish individual bonds and contract in the way they interacted with the families in the area covered is more individual than that of the expanded teams (0.0026) and the expanded teams made more contact with new families than the typical teams (0.0001). Regarding the results of overall efforts and for the bonds established with the community, there was no difference between the two models of teams.

The expanded teams allocated higher scores to their knowledge and interaction with the territory in which they were responsible for health, and there were differences in the distribution of marks between the two models (0.0028). Likewise, the expanded teams allocated higher marks to making joint visits to the territory (0.0036).

As for the interaction with community leaders, the expanded teams allocated higher marks (0.0043), although the typical teams interacted more with health teams in their territory (0.0107). Interaction with education and leisure teams and NGOs were all allocated higher marks by the expanded teams.

Relationship with specialists

Chart 2 shows measures of position and variability (mean, standard deviation and median) of the responses to questions on the teams' relationships with the specialists.

Both models of team allocated low marks to the form of requesting referrals, due to the bureaucracy involved, with no difference between them (0.1061). There was a difference regarding the marks allocated to waiting times between requesting referral and it taking place, with the expanded teams perceiving this to be worse than the typical teams (<0.0001). Specialists' interaction with patients received poor marks from both models, with no difference between them (0.2828). The technical quality of the referral was better in the view of the typical team than that of the expanded team (<0.0001). There was no difference in distribution of marks concerning returning results from the referral to the team, with rather low marks allocated. The marks received for specialists' interaction with the teams were better from the typical teams (0.0017), as was the teams' ability to overcome fragmentation in health care when the patient was being treated in various specialties. Interaction with the home care and care teams received higher marks from the expanded teams (0.0095).

Health promotion activities

Chart 3 shows measures of position and variability (mean, standard deviation and median) of the responses to questions on health promotion activities.

Concerning conducting health education activities, there were differences between the two models of te ams (0.0153), with higher marks allocated by the expanded teams. There was no difference between models concerning conducting self-care educational activities with patients and families (0.1329), with both groups allocating high marks. The expanded teams gave higher marks to lifestyle guidance and to conducting group health education activities. There were no differences between the two models of teams interviewed concerning evaluating patient adherence to regular follow up, evaluating patient's self-care abilities, encouraging patients towards such self-care and evaluating the patient's social support network. The typical teams gave higher marks to encouraging patients to form social support networks (0.0011). There was no difference in the distribution of marks regarding evaluating patients' family ties and evaluating whether they live with family members.

Infrastructure conditions

Chart 4 shows measures of position and variability (mean, standard deviation and median) of the responses to questions on infrastructure conditions.

The marks given concerning patients' privacy were lower among the typical teams (<0.0001), as were those for availability of alcohol gel to disinfect hands (0.5212). The appropriateness of the physical space of the health center received lower marks from the typical teams (<0.0001). Concerning the cleanliness of the unit, there was no difference between the models of team (0.4067), with low marks from both groups.

Discussion

The municipality of Ribeirão Preto has 24 Family Health teams, 8 being expanded and 16 typical. Of the expanded teams, 75% took part in the interviews, and 93.75% of the typical teams agreed to complete the questionnaires, with one team participating only in the pilot project. This adherence to the research may show greater availability on the part of the typical teams to discuss the problems they face and possible solutions as a team. Moreover, the presence of family and community doctors was more frequent during application of the questionnaire, as of the 14 teams interviewed, the doctors from 11 of them participated. In the 8 expanded teams, of the 10 doctors who were part of the unit, including GPs, pediatricians and obstetrician-gynecologists, only 5 participated.

The team's relationship with the population assigned to them and knowledge of the territory

The expanded teams established bonds in the way they interacted more in collective than individual activities, in contrast to the typical teams. This may be due to the fact that home visits, professional care and reception are important resources used by the typical teams in order to establish bonds, and which occur in an individual manner.

The greater contact with families new to the area covered in the form of establishing bonds on the part of the expanded teams may be due to the fact that typical teams have a demand and population assigned to them that is greater than is possible to absorb, hindering them from registering new families in the territory. Thus, the families already registered are given priority in the teams' contact, to the detriment of new families or those which have not yet made use of the health care unit.

In spite of these differences, the result of their efforts to establish bonds seems to be the same for both types of Family Health teams, who gave this question high marks.

Concerning knowledge of the territory, the expanded teams allocated higher marks to knowledge and interaction with the territory covered. However, 57.14% of the typical teams had been formed fewer than five years ago, whereas for the expanded teams, 33.33% had been formed fewer than five years ago. The expanded teams gave higher marks to joint visits to the territory than the typical teams, possibly as their professionals had had a longer period of preparation and training, as the teams were older, some dating back to the establishment of the Family Health Strategy in the municipality. The more recently formed teams were started to meet the population's care needs, without time for due preparation.

Knowing and interacting with community leaders, leisure and education teams and NGOs appears to be greater on the part of the expanded teams, although the typical teams have smaller territories that perhaps do not possess these resources. Interaction with these teams varied considerably between each of the teams, both expanded and typical, revealing the inadequacy of the pattern of urbanization in unevenly distributing resources (Conill, 2008CONILL, E. M. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S7-S27, 2008. Suplemento.; Viana et al., 2006VIANA, A. L. D. et al. Modelos de atenção básica nos grandes municípios paulistas: efetividade, eficácia, sustentabilidade e governabilidade. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, n. 3, p. 577-606, 2006., ²⁰⁰⁸VIANA, A. L. D. et al. Atenção básica e dinâmica urbana nos grandes municípios paulistas, Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S79-S90, 2008. Suplemento.).

Relationship with specialists

In general, the relationships of the Family Health teams, both typical and expanded, was viewed as fairly inadequate by the professionals interviewed, considering the low marks allocated to the questions on this topic. Although there are differences in perception of the waiting times between requesting referral and it taking place, technical quality of referrals and interaction between specialist and team, marks were poor from both models interviewed.

Difficulty accessing other levels of care, a factor that compromises comprehensiveness, was also identified by Conill (2008)CONILL, E. M. Ensaio histórico-conceitual sobre a Atenção Primária à Saúde: desafios para a organização de serviços básicos e da Estratégia Saúde da Família em centros urbanos no Brasil. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, p. S7-S27, 2008. Suplemento. in Florianópolis. The results reflect this difficulty through the poor marks allocated to the bureaucracy of requesting referrals to specialists and the waiting time between the request and the appointment with the specialist. Although the typical teams perceived the delay for referrals to be shorter, marks were low from both models.

Moreover, the areas assigned to the teams interviewed are peripheral, with populations that lack public services, similar to municipalities of over 100,000 inhabitants in which Family Health teams were established in historically neglected areas, compromising the integration of the health care network and the organization of the entire system (the authors…, 2012OS AUTORES respondem: quinze anos de uma agenda em construção: diálogos sobre o PSF no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1343-1345, 2012. Suplemento 1. Disponível em: <http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1413-81232009000800006&lng=pt&nrm=iso>. Acesso em: 10 fev. 2012.
http://www.scielosp.org/scielo.php?scrip... ). Another characteristic of the municipality that contributes to the deficiency of the referral and counter referral system is the large number of complex outpatient cases and the historical hospital coverage in Ribeirão Preto, making it difficult to organize the Family Health Strategy as a priority care model (Viana et al., 2006VIANA, A. L. D. et al. Modelos de atenção básica nos grandes municípios paulistas: efetividade, eficácia, sustentabilidade e governabilidade. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, n. 3, p. 577-606, 2006.).

The principle of comprehensiveness may be compromised by insufficient specialist-patient interaction. The marks were allocated according to the professionals' perception of interaction between specialist and patient. There were clearly no differences in this perception between the two models of teams, i.e. both groups demonstrated that the patients' information and opinions, on which the professionals based their marks, showed dissatisfaction with the referrals.

The teams' ability to overcome fragmentation in care when the patient is treated in a variety of specialties was greater in typical teams, possibly because of their greater facility in sharing information between the different professionals and their greater commitment in terms of taking responsibility for their assigned population. In any case, difficulties in overcoming this fragmentation are largely due to precariousness in returning results from referrals to the teams and to the almost non-existent interaction between specialists and Primary Care professionals. The relationship with specialists appears to be one of the weaknesses of the system, for both the expanded and the typical teams.

Health promoting activities

The marks given to health promoting activities were high for both models of team, being higher from the expanded team concerning conducting educational activities in general. However, one of the points raised by the typical teams was the difficulty in programming collective activities due to the high demands for individual care, as the assigned population was greater than the recommended 800 families per team (Coelho; Jorge, 2009COELHO, M. O.; JORGE, M. S. B. Tecnologia das relações como dispositivo do atendimento humanizado na atenção básica à saúde na perspectiva do acesso, do acolhimento e do vínculo. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1523-1531, 2009. Suplemento.; Sousa; Hamann, 2009SOUSA, M. F.; HAMANN, E. M. Programa Saúde da Família no Brasil: uma agenda incompleta? Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1325-1335, 2009. Suplemento.; Takeda, 2004TAKEDA, S. A Organização de Serviços de Atenção Primária à Saúde. In: DUNCAN, B. B.; SCHMIDT, M. I.; GIUGLIANI, E. R. J. Medicina ambulatorial: condutas de atenção primária baseadas em evidências. Porto Alegre: Artmed, 2004. p. 76-87.). This is reflected in the difference in marks allocated to conducting group health education activities, higher from the expanded team. Even so, all teams conducted collective activities, aiming to guide the population on promoting health, prevention and recovering health. A characteristic that varied between teams was the participation of the different professionals in these activities, as the expanded teams did not have a medical team when conducting health promotion activities.

As with general health promoting activities, specific activities to provide guidance on self-care and to enable patient autonomy received high marks, contributing to the success of treatment and providing greater patient collaboration.

The high marks given to the questions on this topic show that the typical and expanded Family Health teams, which work according to the logic of the strategy, focus more on programmatic activities in the sense of establishing bonds with the community than traditional Primary Care teams, as shown by Facchini et al. (2006)FACCHINI, L. A. et al. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 11, p. 669-681, 2006.. This reality should be encouraged by assigning the population in such a way that demand is not excessive to the point of compromising such activities being conducted.

Encouraging patients to form social support networks is greater in the typical teams, contributing to identifying resources in the communities to solve or handle users social or even health problems (Coelho; Jorge, 2009COELHO, M. O.; JORGE, M. S. B. Tecnologia das relações como dispositivo do atendimento humanizado na atenção básica à saúde na perspectiva do acesso, do acolhimento e do vínculo. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, p. 1523-1531, 2009. Suplemento.).

Infrastructure conditions

Infrastructure conditions clearly differ between typical and expanded teams. This is due to the fact that 10 of the 14 typical teams work in units adapted to be Family Health units, i.e. they were not constructed for that purpose, whereas the expanded teams work in units that provide appropriate care conditions. This reality demonstrates the lack of commitment and planning for adequately establishing the Family Health Strategy in the municipality.

Working in units that do not provide appropriate conditions to function as health care services even compromises patient privacy, as the poor marks the teams allocated to this question show. Moreover, the satisfaction of the professionals who work in units with inadequate, improvised and precarious infrastructure can also be compromised (Facchini et al., 2006FACCHINI, L. A. et al. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 11, p. 669-681, 2006.).

Conclusions

The differences found between expanded and typical Family Health teams show that excess demand, caused by assigning greater populations than recommended to the typical teams, lack of infrastructure and difficulties in relationships with specialists may compromise the performance of expanded and typical teams. An effective referral and counter referral system, more investment and planning in establishing the Family Health Strategy in the municipality and better division of the territory are essential to achieving better results and indicators.

References

Publication Dates

History