ORIGINAL RESEARCH

Assessment of the attributes of primary health care in leprosy control actions

Nayara Figueiredo Vieira^I; Fernanda Moura Lanza^II; Francisco Carlos Félix Lana^III; José Ramón Martínez-Riera^IV

^INurse. Master. PhD student of Nursing of the Federal University of Minas Gerais. Brazil. E-mail: nayarafv5@hotmail.com
^IINurse. PhD Adjunct Professor II, Federal University of São João Del Rei. Brazil. E-mail: fernandalanza@ufsj.edu.br
^IIINurse. PhD Full Professor, Federal University of Minas Gerais. Brazil. E-mail: xicolana@gmail.com
^IVNurse. PhD Full Professor, University of Alicante. Spain. E-mail: josera.ferranna@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.31925

ABSTRACT

Objective: to evaluate the presence and extent of the attributes of primary health care in leprosy control measures in the view of health professionals. Method: this cross-sectional study involved 251 primary health care personnel in Betim. The Assessment Instrument primary care performance in leprosy control measures was used through interviews, with scores calculated as means of Likert Scale responses. The study was approved by the research ethics committee of Minas Gerais Federal University. Results: strengths (≥6.6) were service orientation to gateway attributes, comprehensiveness of services available and provided, and the family; and weaknesses (<6.6) were access, and orientation towards the community and health professionals. Conclusion: when evaluating the presence and extent of the attributes, the health professionals found deficiencies that impaired the quality of leprosy control measures. Measures to address the endemic must be integrated into primary care in order to eliminate this serious public health problem.

Descriptors: Leprosy; primary health care; health services research; nursing.

INTRODUCTION

Leprosy persists as a public health problem in Brazil due to the high endemicity and the physical disabilities of generated. Strategies such as early diagnosis, multidrug therapy (MDT), prevention of physical disabilities and surveillance of household contacts should be incorporated into health services¹.

The Ministry of Health (MOH) recommends as organizational axis of leprosy control actions (LCA) in primary health care (PHC): follow-up of cases and contacts, health promotion through social mobilization and education², guarantee of comprehensive of care³. As a way to operationalize PHC, Brazil adopted the Family Health Strategy (FHS) aiming to replace the care model, historically based on curative actions and centered on specialists, in line with the principles of the Unified Health System (SUS)³.

In this context FHS, LCA are a priority. Evaluating the performance of services means identifying fragilities, effective and quality health strategies by verifying the attributes of PHC⁴. Essential attributes include first contact (gateway), continuity or longitudinality of care, comprehensiveness and coordination⁴. Community guidance, family guidance and cultural competence are also incorporated⁴. It is opportune to discuss the level of integration and decentralization of LCA in PHC because there are problems such as turnover of professionals, resistance to actions, lack of knowledge about signs and symptoms and reference services and low resolution of PHC^5,6. Factors such as prioritization of leprosy in municipal health policies and few training actions contribute to the weakening of decentralization⁷.

The actions carried out by referral services have been focused on the disease and thus remained distant from the principles of the SUS, keeping the PHC far from being a strategy for the reorientation of the care model. The purpose of this study was to evaluate the presence and extent of attributes of primary health care in the implementation of LCA in the view of professionals who work in the services.

LITERATURE REVIEW

Scientific evidence indicates that health care systems organized based on ordering attributes are effective and of high quality⁴. The Primary Care Assessment Tool (PCATool - Brazil)⁸, based on the evaluation of the presence and extent of attributes, has been adopted in Brazil. The instrument specifies structure, process and outcome aspects⁹. By monitoring trends, the Instrument for Assessment of Performance of Primary Health Care in Leprosy Control Actions (PCAT-leprosy ) is a tool that assesses the degree of guidance provided by PHC in LCA^10-12.

The PCAT-leprosy uses essential attributes, namely: access - the way the service is experienced to achieve better results; gateway - implies seeking attention to each new problem; integrality - presupposes the capacity to make arrangements so that the population receives all types of services; continued care - the existence of a regular source of care, which occurs when it is performed by the care is given by the same professional or by the same unit; coordination - availability of information regarding previous problems and services and the recognition of that information⁴. As for derived attributes: family guidance - when patients are considered within their family context and exposure to health threats; community guidance - when there is an assessment of the patients' needs and recognition of their social context⁴; and professional guidance - presupposes skills to perform functions, according to the attributes¹³.

Studies using the PCAT-leprosy demonstrated that problems are related to the derived attributes (community and professional guidance), precisely those that qualify the assistance^10,14,15. Despite limited research records in Brazil evaluating the relationship between epidemiological indicators and the quality of PHC, it is verified that the integration of LCA in primary care has the potential to increase access, making it possible to strengthen the actions¹⁶.

METHODOLOGY

Evaluative and cross-sectional study. The present study is inserted in evaluative research, because it analyzes the relations of causality between different components of the intervention and allows to understand the outcomes¹⁷. The research was carried out in Betim - MG due to its historical and epidemiological importance, because the Santa Izabel Colony was installed there in 1931. From 2002 onwards, there have been investments in the integration of LCA with 90% of the teams trained⁶. In 2015, the municipality presented a detection rate of 3.11 new cases/100 thousand inhabitants, which characterizes as average endemicity. Operational indicators, contact examination and cure are classified as regular, according to parameters of the MOH¹⁸. The coverage of the FHS is around 70%¹⁹. At the time of data collection, there were 97 teams, with 90 FHS units and 7 Community Health Agent Strategy (CHAS) units, both models subordinate to the same policy of care to leprosy. Besides PHC, there is the Reference Service for Leprosy of Citrolandia located in Colônia, a pioneer site in the implementation of CT, responsible for conducting training events in the 1980s⁶.

Data collection took place from February to April 2014, two researchers were trained and prior schedules were performed. We included doctors/nurses who worked in PHC, with the exception of physicians who belonged to the More Physicians Program (MPP) due to their recent inclusion in the work, less than one month prior to the start of data collection. Before the physicians of the MPP were excluded, an interview was conducted and there was a difficulty to understand the language, implying a possible assessment bias. Forty-nine doctors were interviewed. There were 14 exclusions of professionals of the MPP, three refusals and 18 losses due to medical leave, vacations, maternity leave and the impossibility of scheduling. Regarding the nurses, 85 interviews were conducted, with eight losses due to the same reasons above mentioned for the physicians.

The criterion of inclusion of CHAs was to have at least 12 months of experience. This criterion is justified by the fact that acting as an community health agent does not require training in the health area or experience in working with families. When it was not possible to conduct interviews with all CHAs, one agent per team was selected. The CHA interviewed was the one who, at the time of the visit of the researchers, was in the unit and met the inclusion criterion. Thus, 83 interviews were conducted, with 14 losses due to a strike.

The 97 teams are disproportionally distributed in 34 physical units, according to the need of the territory. The criterion of inclusion of managers was to act in PHC services and carry out management activities in the control of leprosy. Thirty-four managers were interviewed, with three losses related to the impossibility of rescheduling.

The PCAT-leprosy in the medical/nursing¹⁰, manager¹¹ and CHA¹² versions was used and the responses were recorded on a Likert-type scale^10-12. The instrument is based on the theoretical framework of PHC³ and in the LCA recommended by the current policy e². It is noteworthy that the attributeprofessional guidance is not contemplated in the PCATool-Brazil⁸, but its inclusion was recommended in another study because the SUS offers training¹³.

The calculation of the score is based on the mean, and on the sum of the items of each attribute divided by the number of items; later this average is transformed into a scale of 0 to 10^10-12. Then the mean represents, within each attribute or calculated score, the overall performance of the PHC in the LCA. As overall result of the PCAT-leprosy assessment, there were three measures: essential score - the average of the essential attributes (access, gateway, continued care, coordination and comprehensiveness of services provided and available); derived score - the mean of the derived attributes (family, community and professional guidance); and, overall score - average of the components of the essential and derived attributes, and this characterizes the degree of orientation. Strong orientation was indicated when the mean score was equal to or greater than 6.6^10-12.

The Pearson chi-square test was used for statistical testing, and the data were analyzed in the IBM SPSS version 19, with a significance level of 5%.

The study was approved by the Research Ethics Committee of the Federal University of Minas Gerais under Opinion nº CAAE 24578213.2.0000.5149 and the participants signed the Informed Consent Term. The study was funded by the Health Surveillance Department (197/2012) and the Foundation for Research Support of the State of Minas Gerais.

RESULTS AND DISCUSSION

Of the 251 interviewees, 53.4% ​​were physicians/nurses, 33.1% were CHAs and 13.5% managers. Physicians/nurses stood out because of the shorter time working in the unit. Moreover, the majority of the participants had received training in LCA. The majority of the interviewees did not assist leprosy cases. However, CHAs said to perform LCA in the territory, as shown in Table 1.

TABLE 1: Distribution of professional variables according to the category of the interviewees. Primary care units. Betim/MG, Brazil, February to April 2014.

† Except these variables were not questioned during data collection.

The overall assessment of the degree of orientation of PHC in the performance of LCA was borderline in the view of physicians/nurses and CHAs (6,7). However, this was not evidenced by the managers (7,3), indicating a distance between what happens in the territory and the planned actions, as shown in Table 2. The absence of a qualified coordination team in LCA at municipal level and political support tends to compromise the integration of actions²⁰. It is necessary to prioritize qualification in the municipal health care policy, as well as commitment on the part of managers⁷.

TABLE 2: Mean scores and percentage of high scores (≥ 6.6) of attributes of primary health care in leprosy control actions according to the interviewees' experience. Betim/MG, Brazil, February to April 2014.

^(*) CHA: Community Health Agent; † Health professionals and community health agents who had not followed a leprosy case did not respond to the items in these blocks and due to the number of missing data (> 50%), it was not possible to calculate the average of these scores; ‡ There are no items in the performance assessment tool on the attribute coordination in the Community Health Agent version.

The essential score was very high (≥ 6.6), and gateway and comprehensiveness of the services available and provided contributed the most to this better evaluation. It is recognized that cases of suspected contamination seek the units, but difficult access compromise the effectiveness of PHC as the first place of choice, resulting in the pilgrimage of clients through the network as the disease progresses. Besides PHC, there is the Leprosy Reference Service at Citrolândia, which is also the gateway to suspected cases and treatment.

Comprehensiveness should characterize the procedures and guidelines given in the PHC⁸. Despite the structural weaknesses, it is undeniable that the expansion of the FHS has promoted advances in health conditions, reduction of maternal and infant mortality, and reduction of infectious and parasitic diseases^21,22.

There was fragility in access; only the group of CHAs evaluated it as strongly oriented, being a bottleneck; studies of PCATool- Brazil ⁸ which evaluated the access to PHC in general and in cases of tuberculosis corroborate this finding. Access barriers are related to delay in consultations and the restricted period of operation of the services ^23-25. In Betim, there were weaknesses in relation to the geographic aspect, poor location of the units, precarious pavements, distant microareas, difficulties in public transportation, restriction in the period of operation and overload of the teams. In leprosy, access depends on the knowledge of the population, availability of instruments to perform the dermatoneurological evaluation, and the presence of trained professionals⁷. The therapeutic itinerary of people with leprosy still reveals the difficulties of PHC professionals to define the suspicion of the signs and symptoms of the disease, whose diagnosis is confirmed only by specialists²⁶.

The experience of monitoring cases improves the evaluation in the overall, essential and derived score. Comparing the proportion of the high score (yes/no) among physicians and nursing professionals and CHAs by presence of case by the Pearson chi-square test, there were significant differences in the comprehensiveness of services provided, community guidance and derived and overall score, as shown in Table 3.

TABLE 3: Mean score, standard deviation, percentage of high score and chi-square test of the attributes of primary care in leprosy actions, according to the experience of the interviewees and absence or presence of a leprosy case. Betim/MG, Brazil, February to April 2014.

^*CHA: Community Health Agent; †Arithmetic mean; ‡SD: standard deviation; §Health professionals and CHAs who did not follow a case of leprosy did not respond to the items of these blocks, and it was not possible to calculate the mean of these scores (missing data > 50%); || There are no items in the performance assessment tool on the attribute coordination in the Community Health Agent version; ¶ X²: Qui-square.

Continuing care, family guidance and coordination are calculated for physicians/nurses and CHAs who followed cases; managers, regardless of this criterion, answered the items.

In coordination, physicians/nurses and managers said that PHC is strongly oriented; however, access problems make it difficult to enter the system, where the service is operative. The teams are responsible and maintain coordination when there is a need for attention elsewhere in the network. Strategies can strengthen PHC as the organization of the gateway, construction of protocols in conjunction with multiprofessional teams, facilitating the coordination, adherence to guidelines and an effective referral and counter-referral service^16,27,28.

Regarding continuing care, there was a positive evaluation from managers (8.2); physicans/nurses (8.6); CHAs (9.3). This is a reflection of the follow-up of cases; these results should be analyzed with caution and the same observation applies to the family guidance, which was evaluated as strongly guided: physicans/nurses (8.8); managers (7.6) and CHAs (8.8). This suggests a different look for the cases followed in the PHC, in which there is the presence of bond, bringing the team closer to the family context.

A study with the PCAT-leprosy tool in Teófilo Otoni- MG pointed out that, in the view of the managers, there is poor guidance in continuous care¹⁰. In this municipality, users have the reference as a source of care, which may justify the low guidance. In Betim, the results were different, possibly reflecting the integration of actions. Tactics such as the user being assisted by the same professional at each supervised dose, search for information about adherence to treatment, and general guidelines can strengthen the continued care.

The strong family guidance shows concern with context, understanding that relationships and conflicts directly influence health. Studies that evaluated the family approach in PHC demonstrated little incorporation of families in the practices and insufficient interest on the part of professionals to know the life conditions of the patients^29,30. In leprosy, families must be inserted in the therapeutic process because the family nucleus represents the group of people at risk of contamination. The items are related to knowledge about the family, suspicion of new cases, examination of contacts, self-care guidelines and the appearance of complications recognized by relatives¹⁰. Families should understand the health-disease process and the drug therapy and facilitate the adherence to treatment. The familiarization with the life and health conditions of the populations allows the understanding of their needs that go beyond curative practices^6,31.

The comprehensiveness of the services provided refers to the items that identify subjects approached by the professionals during consultations⁸. In the PCAT - leprosy, the actions advocated by the MOH such as monitoring suspected cases, diagnosis, general guidelines, supervised dose administration and evaluation of contacts².

There was poor community guidance in PHC, as well as to significant differences in the presence of cases. The weaknesses are related to the unavailability of educational material and lack of active search. Moreover, more than 60% of the physicians/nurses reported not performing actions in the territory. Research carried out with health advisors and community leaders in an endemic municipality of Minas Gerais showed absence of social participation in the control of leprosy and fragility in health education strategies used by PHC professionals who are not capable of provoking spontaneous demand of the population to perform diagnostic actions for suspected cases³².

Studies of PCATool - Brazil⁸ also obtained unsatisfactory scores in community guidance according to the general view of users of PHC and caregivers of children^24,25,33,34. As for studies with PCAT - leprosy, there was also weak community guidance in three municipalities of Minas Gerais¹⁰. These evidences corroborate the results. Thus, incorporating strategies such as reviewing the work process, encouraging user participation, and conducting home visits would facilitate health surveillance and community monitoring^24,35.

In professional guidance, there was weak guidance in LCA and statistical differences in the proportion per case assisted by CHA. The majority of the participants reported training, suggesting little effectiveness, and it was necessary to evaluate methodologies and periodicity. Scientific evidence indicates that training increases detection, makes professionals responsible for the epidemiological situation and stimulates disease control actions³⁶.The challenge is to overcome the insecurity of professionals in carrying out the diagnosis and treatment. Thus, qualification has the potential to modify an epidemiological situation.

CONCLUSION

The strong guidance of the service in the attributes gateway, comprehensiveness of services available and provided, family guidance; and the weaknesses in access and community and professional guidance demonstrate that it is necessary to strengthen the decentralization policy. It is important to value the care model based on health surveillance and identification of needs of the population. This study can support future research regarding the effectiveness of the offered training, because despite training, the teams feel unprepared.

However, when assessing the presence and extent of primary care attributes in LCA, the professionals found deficiencies that impair the quality of the service. It is necessary to integrate the actions of control of the endemicity to eliminate this serious public health problem, mainly in regions as Betim, scenario of a former colony.

The limitations of this study are the strike of CHAs that occurred during the research, the recent inclusion of physicians/nurses in the PHC service and the difficult schedule of the participants. There was a possible bias of intention on the part of managers, because they were evaluating the services that they coordinate.

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