Ar
ticle
evaluation of primary child health care in Brazil: a systematic
review of methods and results
Abstract
This systematic review analyzes themethods and instruments employed to evaluate primary child health care in Brazil and their main findings. The review was conducted in accordance with the recommendations of the PRISMA (Pre-ferred Reporting Items for Systematic Reviews and Meta-Analyzes) statement. Searches of articles focusing on children aged between zero and five years published between 1994-2006 were conduct-ed of the following databases: MEDLINE, LILACS, IBECS, BDENF, PubMed, PsycNET, Cochrane, and CINAHL. The searches yielded 3,004 arti-cles. After initial screening and the application of the STROBE and SRQR criteria, 21 articles were included in the review. About 52% of the articles were conducted in the Southeast region and 95.2% were published as of 2010. The most commonly used evaluation tool was the Primary Care Assess-ment Tool Child Edition, adapted and validated for use in Brazil (52.4%). The quality of primary child care was inadequate. The main limitations included poor access to services, inadequate facil-ities, and underqualified health staff. There has been a significant increase in the number of eval-uation studies conducted in Brazil in recent years. Despite advances in health care across the country, the findings point to the need for a more effective response to the challenges in ensuring comprehen-sive primary child care in Brazil.
Key words Primary Health Care, Child Health, Evaluation, Systematic Review
George Sobrinho Silva (https://orcid.org/0000-0001-9965-6576) 1
Daisy de Rezende Figueiredo Fernandes (https://orcid.org/0000-0002-8968-6306) 1 Cláudia Regina Lindgren Alves (https://orcid.org/0000-0002-0885-1729) 2
1 Departamento de Enfermagem, Universidade Federal dos Vales do Jequitinhonha e Mucuri. Rodovia MGT 367, Km 583, 5000, Alto da Jacuba. 39100-000 Diamantina MG Brasil. georgesobrinho@ yahoo.com.br 2 Departamento de Pediatria, Faculdade de Medicina, Universidade Federal de Minas Gerais. Belo Horizonte MG Brasil.
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introduction
Brazil has made significant strides in improv-ing child health in recent decades as a result of improved living conditions, the
advancement
ofchildren’s rights, and
advances in the country’s health policy1,2. This is illustrated by a sharp fallin infant mortality rates1,3, from 85.6 per 1,000
live births in 1980 to 13.8 in 20154, when Brazil
achieved target 4 of the Millennium Develop-ment Goals (Reduce by two-thirds, between 1990 and 2015, the under-five mortality)3.
Brazil began to implement specific interven-tions targeting child health in the 1960s with the Maternal and Child Health Program. In the 1990s, initiatives began to incorporate policies designed to expand the coverage of public health services, as in the case of the family health and community health agent programs. With the re-structuring of primary health care services, it was possible to improve the distribution of health care professionals across underserved areas and widen access to health services, positively impact-ing child health indicators2. The creation of the
National Policy for Comprehensive Child Health Care (PNAISC, acronym in Portuguese), in 2015, was the culmination of interinstitutional efforts to enhance actions directed at young children and vulnerable groups, based on the principles of the right to life, equality, comprehensive human-ized care, and participatory management2.
Brazil’s Family Health Strategy (FHS) has consolidated primary health care, expanding service coverage across the country. However, numerous factors continue to limit coverage, in-cluding the coexistence of traditional and family care models in the same service, structural and organizational factors, and staff shortages, driv-ing the institutionalization of evaluation pro-cesses to inform strategies to strengthen primary health care5-7.
Evaluation is a process in which, based on valid and legitimate information, value judg-ments are made about interventions, processes, and outcomes with a view to enhancing service management performance, facilitating change, decision-making, and the pursuit of quality7. The
growing recognition of the importance of eval-uation has led to the development of a suite of instruments and methods for evaluating the ad-equacy of public services in Brazil over the last three decades8. This process has been led by the
Ministry of Health, with initiatives like the “Sala
de Situação” or “Health Situation Room” (2002),
the Assessment for Improving the Quality of the
Family Health Strategy - AIQ (Avaliação para a
Melhoria da Qualidade - AMQ)9, the Primary
Care Assessment Tool10 (2010), and the
Nation-al Program for Improving Access and QuNation-ality in Primary Care (2011)9. In addition, research
groups at universities across the country have also developed a number of initiatives8.
In view of the need to synthesize the knowl-edge accumulated in recent years, this review an-alyzes the methods and instruments employed to evaluate primary child health care in Brazil and their main findings.
Methods
We conducted a systematic review based on the recommendations set out in the PRISMA (Pre-ferred Reporting Items for Systematic Reviews and Meta-Analyses) statement11. Searches were
conducted of the databases Virtual Health Li-brary, Brazil (MEDLINE, LILACS, IBECS, and BDENF), PubMed, PsycNET, Cochrane, and CINAHL, using the following search terms:
“pri-mary health care OR family health strategy AND evaluation AND child health OR child”, based
on the DeCS (Health Sciences Descriptors) and MeSH (Medical Subject Headings).
We included studies evaluating primary health care services for children aged 0 to 19 years (focusing on the zero to five-years age group) published in English, Spanish and Portuguese between January 1994 (the year in which the FHS was created) and September 2016. Litera-ture reviews, theses, dissertations, editorials, case study reports, studies with data on non-Brazilian children, and studies that did not meet 80% of the required items of the methodological quality scales used by this study were excluded.
The methodological quality of observation-al studies was assessed in accordance with the STROBE12 (Strengthening the reporting of
ob-servational studies in epidemiology) statement, consisting of a checklist of 22 items that should be addressed in articles. The version translated and validated for use in Brazil in 200813
establish-es article quality categoriestablish-es. Articlestablish-es that meet at least 80% of the items are classified as category
“A”12,13. Qualitative studies were assessed using
the Standards for Reporting Qualitative Research (SRQR)14. Studies that used both quantitative
and qualitative methodologies were assessed us-ing both instruments and included if they met at least 80% or higher of the items of one of the instruments. One independent reviewer assessed
aúd e C ole tiv a, 25(8):3185-3200, 2020
methodological quality and two reviewers evalu-ated thematic eligibility.
results
The searches yielded 3,004 articles, 538 of which were excluded because they were duplicates. A to-tal of 2,333 articles were excluded after the anal-ysis of the titles and abstracts because they failed to meet the study eligibility criteria. The full texts of the remaining citations were then examined, resulting in the exclusion of 99 articles because they failed to meet the study inclusion criteria. The remaining articles were then assessed against the STROBE and SRQR checklists. A total of 13 publications were excluded because they failed to meet at least 80% of the items, resulting in a final sample of 21 articles. The article selection pro-cess is shown in Figure 1.
Table 1 presents the general characteristics of the selected studies. Around 95% of the arti-cles where published after 2009. All the studies used quantitative methodologies and two used a combination of quantitative and qualitative methodologies. We did not find any qualitative studies that met the inclusion criteria. The most commonly used evaluation instrument was the Primary Care Assessment Tool Child Edition (PCAT-CE) adapted and validated for use in Bra-zil (52.4%). The other studies used instruments developed by the researchers, except for a study conducted in Maceió in 200315, which used the
AIQ.
Only two studies16,17 included both health
care professionals and service users. In 85.7% of the studies, only parents and/or guardians evaluated services, in the majority of cases the children’s mothers. In the other studies, doctors and nurses evaluated services. The studies eval-uated children’s and young people’s services, with 61.9% of studies focusing specifically on the zero to five-year age group. Some studies focused on specific groups, such as children living with HIV18, quilombolas19, and children hospitalized
for ambulatory care sensitive conditions20.
The studies were conducted in areas with varying population characteristics, ranging from state capitals to rural communities. Eleven of the 21 studies were conducted in the Southeast re-gion, nine of which in the State of Minas Gerais (Figure 2).
Table 2 shows a synthesis of the methods and main conclusions of the selected articles. All the studies assessed the performance of family health
teams, 52.4% investigated traditional health cen-ters or a mixture of traditional and FHS cencen-ters, and 14.3% addressed other types of models. Al-most all of the studies investigated service struc-ture and work processes. The main aspects of care investigated were: primary care attributes (47.7%); specific actions developed by prima-ry health care services, such as immunization programs, acolhimento or “receptiveness”, and child health surveillance (33.3%); care structure (9.5%); and health care professional training and development (9.5%).
Only one study, conducted in the State of Paraná in 201521 using the PCAT-CE, showed
that children’s health care services provided un-der the FHS achieved the minimum cut-off score for service quality. In the studies that used this evaluation tool, the lowest-scoring primary care attributes were “first contact accessibility”,
“fam-ily centeredness”, and “community orientation”,
while the highest-scoring attributes were “first
contact utilization”, “longitudinality”, and “coor-dination-information system”. The FHS obtained
higher scores in four of the six studies that com-pared the performance of FHS centers and tradi-tional health centers20-23. Furthermore, the
find-ings of these studies also showed that the FHS was the preferred service among service users.
The studies that employed other instruments used different aspects of primary care to evaluate care quality. One of the highest-scoring aspects was the patient-health care professional
relation-ship16,24,25. However, these studies also
highlight-ed a number of problems, including: difficulties in accessing services, underqualified profession-al staff16,17,26,27, staff shortages16,26, poor structure
and shortage of materials26, and an emphasis on
disease-based curative care over health promo-tion and disease prevenpromo-tion16,17,24,25.
Discussion
The findings show that the most commonly used tool for evaluating primary child care in Bra-zil was the PCAT-CE. Furthermore, the studies mainly used quantitative methodologies, in-volved parents/guardians and health care pro-fessionals, covered all regions of Brazil, and con-cluded that care quality was inadequate.
The fact that the large majority of articles where published after 2009 reflects the trend in national scientific output in recent years28-30. In
this respect, the quality of national publications has been the target for criticism, particularly due
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to the lack visibility of Brazilian research in inter-national journals28,30. The large number of
arti-cles excluded from this review in the screening for methodological quality stage is a reflection of this situation. The rise in the number of publications in the field of health care evaluation is linked to the expansion of postgraduation programs and an increase in research funding in the country1,8.
Over the last two decades, studies conducted by research groups in partnership with the Ministry of Health have driven the development of con-ceptual and methodological frameworks and the application of evaluation as management tool8.
The predominance of quantitative methods was also found by a review of evaluation stud-ies conducted between 2000 and 200631. In this
respect, until recently, qualitative approach-es were seen to have lapproach-ess methodological rigor, thus hindering their publication in high-impact journals32. The combination of different
meth-odological approaches provides a broader and deeper understanding of the phenomena and processes of concern33. The fact that none of the
articles used only qualitative methods suggests that the understanding of the underlying factors influencing the evaluations provided by service users and professionals may be limited.
The review shows that the majority of stud-ies were conducted in the Southeast and South regions, which is consistent with the findings of a review of Brazilian literature in the field of pediatrics conducted by Gonçalves et al.28. In
this regard, the majority of Brazil’s higher edu-cation and research institutions are concentrat-ed in these regions, facilitating their integration with services and the development of evaluation studies. The integration of education institutions with health services results in training and tech-nical collaboration, fruits of joint research based on health service needs18.
Figure 1. Flow diagram of the article selections process, Belo Horizonte, Minas Gerais, Brazil, 2017.
aúd e C ole tiv a, 25(8):3185-3200, 2020 c har t 1. C har ac te rist ics o f the st udies inc lud ed in the sy st emat ic r ev ie w . B elo H or iz ont e, M inas Ge rais, B razil, 2017. A u tho r (y ear) Jour nal Stud y lo cat io n M etho d olo gical ap pr oac h ev al uat io n inst rume nt Sample/A ge g roup O b je ct iv e Sil va e t al. (2016) 18 R ev B ras E n fer m Santa M ar ia (R GS) C ross-se ct io nal st ud y PCA T -CE 71 c hildr en and a dolesc ents ag ed 0 to 19 y ear s li ving w ith HIV To c ompar e the q ualit y health car e p ro vid ed t o c hildr en and ad olesc ents li ving w ith HIV a cr oss t yp es o f se rv ic es base d o n the e xp er ie nc es o f famil y me mb er s/guar dians H arzhe im et al. (2016) 42 C iên S aúd e C ole t R io d e J ane ir o (RJ) C ross-se ct io nal st ud y PCA T -CE 3,145 c hildr en ag ed 0 t o 12 y ear s To e val uat
e the limits and p
ossib ilit ies o f the a dv anc es ma de in pr imar y health car e in R io d e J ane ir o, base d o n the e xp er ie nc es of b oth a dult and c hild se rv ic e use rs Sil va e Fr ac ol li (2016) 37 R ev B ras E n fer m A lf enas micr o health r eg io n (MG) Quant itat iv e, cr oss-se ct io nal e val uat io n st ud y PCA T -CE 330 par ents/guar dians o f c hildr en ag ed 0 t o 2 y ear s. To e val uat e car e se rv ic es f or c hildr en ag ed und er tw o y ear s pr ov id ed und er the F amil y H ealth St rat eg y O liv eir a e V er issimo (2015) 21 R ev Esc Enfer m USP C olo mb o (PR) C ross-se ct io nal st ud y w ith q uant itat iv e desig n PCA T -CE 482 par ents/guar dians o f c hildr en ag ed up t o o ne y ear To c ompar e the e xt ent t o w hic h p rimar y c hild car e att rib u tes ar e o p er at io naliz ed a cr oss lo cal FHS car e c ent er s and tr adit io nal health c ent er s A raújo et al. (2014) 38 A cta P aul E n fer m A municipalit y in the Stat e o f Par aná (PR) D escr ip ti ve, cr oss-se ct io nal e val uat io n st ud y PCA T -CE 548 c hildr en ag ed und er12 y ear s To id ent ify the e xt ent t o w hic h the famil y c ent er edness and co mm unit y o rie ntat io n att rib u tes ar e o p er at io naliz ed in pr imar y c hild car e se rv ic es Fer rer et al. (2014) 20 H ealth Policy Plan São P aulo (SP) D escr ip ti ve, cr oss-se ct io nal anal yt ical st ud y PCA T -CE 501 c hildr en ag ed 0 t o 14 y ear s hospitaliz ed f or amb ulat or y car e se nsit iv e c ondit io ns To c ompar e the lo ng it udinalit y o f car e in tw o car e mo de ls fr om the p er sp ec ti ve o f se rv ic e use rs, c or re lat
ing the finding
s w ith the ut ilizat io n o f FHS se rv ic es M esq uita Filho e t al. (2014) 39 C iên S aúd e C ole t Pouso A le gr e (MG) O bse rv at io nal, anal yt ical cr oss-se ct io nal st ud y PCA T -CE 419 c hildr en ag ed 0 t o 24 mo nths re gist er ed in the lo cal p rimar y health car e se rv ic e To e val uat e att rib u tes o f p rimar y car e f or c hildr en ag ed 0 t o 2 y ear s fr om the p er sp ec ti ve o f par
ents and guar
dians and id ent ify p ossib le influe ncing fa ct or s M ar ques et al. (2014) 19 C iên S aúd e C ole t São F rancisc o (MG) D escr ip ti ve, cr oss-se ct io nal anal yt ical st ud y PCA T -CE 76 par ents/guar dians o f c hildr en ag ed 0 t o 5 y ear s r eg ist er ed in the FHS To e val uat e the att rib u tes o f p rimar y c hild car e fr om the p er sp ec ti ve o f a q uilo mb ola c omm unit y in the no rth o f the Stat e o f M inas Ge rais it c ont in ues
Sil c har t 1. C har ac te rist ics o f the st udies inc lud ed in the sy st emat ic r ev ie w . B elo H or iz ont e, M inas Ge rais, B razil, 2017. A u tho r (y ear) Jour nal Stud y lo cat io n M etho d olo gical ap pr oac h ev al uat io n inst rume nt Sample/A ge g roup O b je ct iv e Pe rez et al. (2014) 16 R ev S aúd e Púb lica V espasiano (MG) C ross-se ct io nal st ud y Quest io nnair e elab or at ed by the resear che rs 77 p rimar y car e p ro fessio nals (d oc to rs, n ur ses, n ur sing te chnicians, and c omm unit y health ag ents) and 293 c hildr en ag ed und er 5 y ear s To anal yz e the st re ngths and w eaknesses o f the FHS fr om the p er sp ec ti ve o f health car e p ro fessio nals and se rv ic e use rs R oc ha e Pe dr oza (2013) 26 Te xt o C ont ext o E n fer m Que ima das (PB) C ross-se ct io nal st ud y Quest io nnair e elab or at ed by the resear che rs 204 c hildr en b or n in 2009 li ving in Que ima das To e val uat e d ev elo pme ntal f ol lo w-up in the c ont ext o f p rimar y health car e in Que ima das M od es e Gaív a (2013) 43 Online B raz J N ur s C uiabá (MT ) D escr ip ti ve ev al uat io n st ud y Quest io nnair e elab or at ed b y the r esear che rs 12 p rimar y health car e d oc to rs and 14 n ur ses To e val uat e the st ruc tur e o f p rimar y car e c ent er s p ro viding se rv ic es f or c hildr en und er o ne y ear o f ag e fr om the p er sp ec ti ve of d oc to rs and n ur ses M od es e Gaív a (2013) 40 Esc A nna Ne ry C uiabá (MT ) D escr ip ti ve ev al uat io n st ud y Quest io nnair e elab or at ed by the resear che rs 127 mothe rs/guar dians o f c hildr en ag ed und er o ne y ear To e val uat e the sat isfa ct io n o f mothe rs/guar dians o f c hildr en ag ed und er o ne y ear r eg ar ding car e d eli ve ry at p rimar y car e ce nt er s in C uiabá Sales e t al. (2013) 15 J H um G ro w th D ev M ac eió (AL) D escr ip ti ve cr oss-se ct io nal st ud y Ev al uat io n fo r Qualit y Imp ro ve me nt - AIQ (AIQ) A ll d oc to rs (66) and n ur ses (66) w or king in the FHS To in vest ig at e the e xt ent t o w hic h c
hild health car
e a ct io ns ar e de ve lo p ed in the FHS M ac ha do et al. (2012) 24 C iên S aúd e C ole t Fo rtaleza (CE) C ross-se ct io nal po pulat io n-base d st ud y Quest io nnair e elab or at ed by the resear che rs 350 families o f c hildr en ag ed und er 5 y ear s using pub lic health se rv ic es To d escr ib e the dime nsio ns o f a cc ess t o car e and fa ct or s asso ciat ed w
ith the sat
isfa ct io n o f mothe rs o f c hildr en ag ed und er fiv e y ear s Leão e t al. (2011) 22 R ev B ras Saúd e M at er Infant M ont es C lar os (MG) C ross-se ct io nal st ud y PCA T -CE 350 par ents/guar dians o f c hildr en ag ed 0 t o 2 y ear s. To c ompar e p rimar y c hild car e att rib u tes b etw ee n the FHS and othe r c hild car e se rv ic es in the m unicipalit y base d o n the ev al uat io n o f par ents/guar dians it c ont in ues
aúd e C ole tiv a, 25(8):3185-3200, 2020 A u tho r (y ear) Jour nal Stud y lo cat io n M etho d olo gical ap pr oac h ev al uat io n inst rume nt Sample/A ge g roup O b je ct iv e Luhm et al. (2011) 25 R ev S aúd e P ub lica C ur it iba (PR) D escr ip ti ve st ud y Inf or mat io n fr om the m unicipal imm unizat io n inf or mat io n sys tem 2,637 c hildr en ag ed 12 t o 24 mo nths b or n in 2002 and li ving in C ur it iba To e val uat e an imm unizat io n p ro gr am f or c hildr en ag ed be tw ee n 12 and 24 mo nths in C ur it iba, base d o n inf or mat io n fr om the m unicipal imm unizat io n inf or mat io n sy st em Leão e Cald eir a (2011) 44 C iên S aúd e C ole t M ont es C lar os (MG) C ross-se ct io nal st ud y PCA T -CE 350 par ents/guar dians o f c hildr en ag ed und er 2 y ear s To d et er
mine the asso
ciat io n b etw ee n p rimar y car e att rib u tes and the q ualificat io n o f FHS d oc to rs and n ur ses C osta et al. (2011) 17 C iên S aúd e C ole t Te ix eir as (MG) C ross-se ct io nal st ud y w ith q uant itat iv e and qualitat iv e d esig n Quest io nnair e elab or at ed by the resear che rs 161 mothe rs o f c hildr en ag ed und er 2 y ear s and 35 health w or ke rs fr om 4 p rimar y car e c ent er s To e val uat e c
hild health car
e und er the F amil y H ealth P ro gr am R ib eir o et al. (2010) 41 C ad S aúd e Púb lica D iamant ina (MG) D escr ip ti ve cr oss-se ct io nal st ud y PCA T -CE 384 par ents/guar dians o f c hildr en ag ed 0 t o 6 y ear s. To e val uat e r ec ep ti ve ness in the FHS as an ap pr oa ch t o re ce iv ing , and list ening t o pat ie nts and b ring ing t og ethe r those w ho car e and those w ho ar e car ed f or , fr om the p er sp ec ti ve o f par
ents and guar
dians. C ald eir a et al. (2010) 23 C iên S aúd e C ole t M ont es C lar os (MG) H ouse hold s ur ve y Quest io nnair e elab or at ed by the resear che rs 595 mothe rs o f c hildr en ag ed und er 2 y ear s To e val uat e the q ualit y o f mat er nal and c hild car e und er the FHS and c ond uc t a c ompar at iv e anal ysis o f t ra dit io nal and FHS car e c ent er s. Figue ir as et al. (2003) 27 C ad S aúd e Púb lica B elém (P A) D escr ip ti ve cr oss-se ct io nal st ud y Quest io nnair e elab or at ed by the resear che rs 80 FHS d oc to rs and 80 FHS n ur ses To e val uat e the kno w le dg e and p ra ct ic e o f c hild d ev elo pme ntal sur ve illanc e b y p rimar y car e p ro fessio nals in B elém PCA T -CE: P rimar y C ar e A ssessme nt T ool C hild Edit io n, a dap te d and v alidat ed f or use in B razil; FHS: F amil y H ealth St rat eg y. c har t 1. C har ac te rist ics o f the st udies inc lud ed in the sy st emat ic r ev ie w . B elo H or iz ont e, M inas Ge rais, B razil, 2017.
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A study conducted by Fracolli et al.34
con-cluded that the PCAT is the most adequate tool for evaluating the quality of care services provid-ed under the FHS and allows researchers to assess the extent to which primary care attributes are operationalized10. The Essential Score is made
up of the attributes Strength of affiliation, First contact accessibility/utilization, Longitudinality, Coordination-integration of care and informa-tion systems, and Comprehensiveness of ser-vices available and provided. The Derived Score is made up of the attributes Family centeredness and Community orientation10. The analysis of
each of these attributes enables health managers to tailor actions to the determinants of care qual-ity in each service/setting. One of the advantag-es of the PCAT is that the instrument has been validated and applied in other countries19,34,35.
The tool has three editions (adult, child, and pro-fessional), which enables comparisons between different actors and types of primary care orga-nizations10,15.
Evaluation instruments should be able to identify service strengths and weaknesses and be recognized by the scientific community34. The
only evaluation instrument used in more than one study was the PCAT-CE. The other instru-ments used in the studies were mainly elaborated and validated by the researchers according to the
specific objectives of each study. Although this might allow researchers to investigate the specific aspects of given services and settings, the use of individual tools limits comparison and the ex-trapolation of results. In this respect, cross-cul-tural adaptation and validation may not always be sufficient to allow the evaluation of different contexts and the peculiarities of different types of services.
Besides the evaluation of service perfor-mance, some of the studies compared different primary care models. Although it recognizes dif-ferent models, the National Primary Health Care Policy10 states that the FHS is the basic care
mod-el underpinning primary care services in Brazil. The FHS differs from other models insofar as multiprofessional health teams are responsible for delivering a suite of integrated services to a specific number of families in a specific geo-graphical area10, while traditional primary care
centers emphasize clinical and health interven-tions10.
Although evidence shows that the FHS per-forms better in comparison to traditional care models, the review shows that this model has a number of limitations. In this respect, accessibili-ty, understood as people’s ability to get care easily and conveniently36, was one of the lowest-scoring
attributes.
Figure 2. Distribution of studies by region, Belo Horizonte, Minas Gerais, Brazil, 2017.
aúd e C ole tiv a, 25(8):3185-3200, 2020 c har t 2. R es ults o f the anal ysis o f the ar tic les inc lud ed in the r ev ie w , B elo H or iz ont e, M inas Ge rais, B razil, 2017. A u tho r (y ear) ty p e o f se rv ic e ev al uat ed it em e val uat ed Se rv ic e q ualit y indicat or s/ c onc lusio ns Sil va e t al. (2016) 18 P rimar y health car e se rv ic es (FHS and t ra dit io nal car e c ent er s) and sp ecialist ou tpat ie nt se rv ic es f or c hildr en and a dolesc ents liv ing w ith HIV P rimar y car e att rib u tes* T he att rib u tes sc or ed hig he r in the sp ecialist se rv ic e (6.4)** than in the p rimar y health car e se rv ic es (6.1)**. N eithe r o f the se rv ic es ac hie ve d the minim um q ualit y cu t-o ff sc or e (6.6)*** f or “g ene ral it ems ”. T he lo w est-sc or ing att rib u tes w er e “famil y c ent er edness ” and “c omm unit y o rie ntat io n” . A ll othe r att rib u tes, e xc ep t “ se rv ic es p ro vid ed” (6.4)**, a chie ve d the minim um q ualit y cu t-o ff sc or e, indicat ing st ro ng o p er at io nalizat io n o f the att rib u tes r elat ed t o a cc ess, lo ng it udinalit y, c omp re he nsi ve ness and c oo rdinat io n. P rimar y car e se rv ic es w er e not the p rincipal sour ce o f car e f or 56% o f the sample. H arzhe im e t al. (2016) 42 FHS and mix ed health c ent er s P rimar y car e att rib u tes* T he re was no sig nificant diff er enc e in sc or es b etw ee n FHS and mix ed mo de l health c ent er s f or the “g ene ral” and “esse nt ial” it ems. N eithe r the FHS (6.1)** no r the mix ed health c ent er s (6.0)** a chie ve d the minim um q ualit y cu t-o ff sc or e***. T he FHS ce nt er s sc or ed hig he
r than the mix
ed health c ent er s. I n b oth t yp es o f se rv ic es, the hig hest-sc or ing att rib u tes w er e “st re ngth o f affiliat io n” (7.6 and 7.4)** and “u tilizat io n” (7.9 and 7.9)**. T he lo w est-sc or ing att rib u tes w er e “a cc essib ilit y” (4.8 and 4.5)**, “famil y c ent er edness ” (5.4 and 5.5)**, and “c omm unit y o rie ntat io n” (5.4 and 3.9)**. Sil va e Fr ac ol li (2016) 37 FHS in r ur al ar eas P rimar y car e att rib u tes* T he “g ene ral sc or e” (6.2)** and “esse nt ial sc or e” (6.4)** faile d t o a chie ve the q ualit y cu t-o ff sc or e***. T he att rib u tes “u tilizat io n” (8.0)**, “ lo ng it udinalit y” (6.7)**, “ car e int eg rat io n” (6.9)**, and “inf or mat io n sy st ems ” (7.0)** a chie ve d the q ualit y cu t-o ff sc or e. T he att rib u tes “a cc essib ilit y” (4.9), “ av ailab le se rv ic es ” (5.2)**, “ se rv ic es p ro vid ed” (6.5)**, “ famil y c ent er edness ” (5.1)**, and “c omm unit y o rie ntat io n” (5.7)** faile d t o a chie ve the minim um sc or e. T he st ud y hig hlig ht ed that limitat io ns in a cc ess ma y b e link ed t o same-da y c ons ultat io n sc he duling p ro ble ms and difficult ies in o btaining guidanc e b y t ele pho ne. T he p oo r e val uat io n o f “c omp re he nsi ve ness ” was r elat ed t o the und er pr ov isio n o f p rimar y car e. L ow sc or es f or “famil y c ent er edness ” and “c omm unit y or ie ntat io n” indicat e that little r eg ar d is paid t o the o pinio n o f par ents/guar dians and c har ac te rist ics o f famil y and c omm unit y gr oups.
FHS was the main car
e sour ce in 56.3% o f the sample. O liv eir a e V eríssimo (2015) 21 FHS and tradit io nal car e ce nt er s in ur ban ar eas P rimar y car e att rib u tes* A ll att rib u tes sc or ed hig he r in the FHS c ent er s than in the t ra dit io nal health c ent er s. FHS c ent er s sho w ed st ro ng er o p er at io nalizat io n (6.6)*** than t ra dit io nal health c ent er s (3.9)**. I n the FHS ce nt er s, the att rib u
tes that faile
d t o ac hie ve the q ualit y cu t-o ff sc or e w er e “a cc essib ilit y” (5.1)**, “ lo ng it udinalit y” (5.4)**, “inf or mat io n sy st ems ” (6.3)**, “ av ailab le se rv ic es ” (6.2)**, and “c omm unit y or ie ntat io n” (5.6)**. I n the tr adit io nal health ce nt er s, no ne of the att rib u tes ac hie ve d the minim um qualit y cu t-o ff sc or e. T he fa ct or s that e xplaine d lo w sc or es in b oth t yp es o f se rv ic es w er e: p oo r a cc
ess and wait t
imes, la ck o f a vailab ilit y o f inf or mat io n re gist er s, la ck of a cc ess to child health car e se rv ic es, and ins ufficie nt kno w le dg e ab ou t the famil y and the co mm unit y. D espit e sat isfa ct or y r es ults f or the FHS, the st ud y hig hlig ht ed the ne ed t o r ev ie w c
hild health car
e a ct io ns. A raújo e t al. (2014) 38 P rimar y health car e se rv ic es C omm unit y or ie ntat io n and famil y c ent er edness* T he att rib u tes “famil y c ent er edness ” (4.4)** and “c omm unit y o rie ntat io n” (5.1)** faile d t o a chie ve the q ualit y cu t-o ff sc or e**. T he st ud y hig hlig ht ed that se rv ic es a do pt a p re do minantl y t ra dit io nal car e ap pr oa ch c ent er ed o n the indi vid ual r athe
r than the famil
y/ co mm unit y. it c ont in ues
Sil A u tho r (y ear) ty p e o f se rv ic e ev al uat ed it em e val uat ed Se rv ic e q ualit y indicat or s/ c onc lusio ns Fe rr er e t al. (2014) 20 FHS and tradit io nal car e cen ter s Lo ng it udinalit y o f car e* T he att rib u te “lo ng it udinalit y” faile d t o a chie ve the q ualit y cu t-o ff sc or e (4.9)**. FHS se rv ic es sc or ed hig he r than t ra dit io nal car e ce nt er s f or this att rib u te. A round 66% o f FHS pat ie nts c onsid er ed the att rib u te t o b e a de quat e. M esq uita Filho e t al. (2014) 39 P rimar y health car e se rv ic es P rimar y car e att rib u tes* T he st ud y r ep or te d w eak o pe rat io nalizat io n o f p rimar y car e att rib ut es. T he “g ene ral sc or e” was 5.2** and 85.0% o f the e val uat io ns w er e ne gat iv e. T he o nl y att rib ut e t o a chie ve the q ualit y cu t-o ff sc or e** was “lo ng it udinalit y” (7.8)**. T he lo w est-sc or ing att rib ut es w er e “a cc essib ilit y” (4.7)** and “a vailab le se rv ic es ” (2.9)**, r ec ei ving lo w sc or es fr om 91.5% and 94.6% o f se rv ic e use rs, r esp ec ti ve ly . C oo rdinat io n o f pr imar y health car e sc or ed hig he r amo ng child FHS se rv ic e use rs than in those re gist er ed in tr adit io nal pr imar y car e ce nt er s (PR = 0.34). A round 77.1% o f se rv ic e use rs r ep or te
d that the FHS was the
ir p re fe rr ed se rv ic e f or c hild car e. M ar ques e t al. (2014) 19 FHS in a r ur al quilo mb ola co mm unit y P rimar y car e att rib u tes* T he “g ene ral it ems ” faile d t o a chie ve the q ualit y cu t-o ff sc or e (6.4)**. T he att rib ut es “u tilizat io n” (9.1)** and “inf or mat io n sy st ems ” (6.9)** a chie ve d the q ualit y cu t-o ff sc or e. T he lo w est-sc or ing att rib ut es w er e “a cc essib ilit y” (4.8)** and “famil y c ent er edness ” (3.8)**. T he lo w p rimar y car e att rib ut e sc or es s ug gest the re is a g ap b etw ee n a ct ual and d esir ed a ct io ns. T he FHS was the p re fe rr ed se rv ic e f or child car e f or mo re than 80% o f the se rv ic e use rs. Pe rez e t al. (2014) 16 FHS Se rv ic e q ualit y, health p ro fessio nal co mm unicat io n, and car e p ro ble ms P ro fessio nals g av e hig he r sc or es f or a cc essib ilit y and car e q ualit y than se rv ic e use rs. P ar ents/guar dians and p ro fessio nals id ent ifie d similar w eaknesses (la ck o f a cc ess, staff sho rtag es, and und er qualifie d p ro fessio nals) and st re ngths (c omm unicat io n b etw ee n co mm unit y health ag ents, p ro visio n o f e ducat io nal mat er ial, and p ediat ric car e). T he most c ommo nl y r ep or te d p ro ble m was staff sho rtag es. T he majo rit y o f p ro fessio nals hig hlig ht ed ins ufficie nt t raining in t er ms o f n umb er , c ont ent, and me tho ds. I n ge ne ral, b oth p ro fessio
nals and par
ents/guar dians r ep or te d b eing sat isfie d w ith the se rv ic es, d espit e the failing s. P ar ent/guar dian sat isfa ct io n/dissat isfa ct io n t end ed t o b e link ed t o the health p ro fessio nals and a cc ess t o health p ro mot io n and disease p re ve nt io n se rv ic es, r esp ec ti ve ly . R oc ha e Pe dr oza (2013) 26 FHS in ur ban and rur al ar eas D ev elo pme ntal fol lo w-up st ruc tur e and p ro cess T he e val uat io n o f car e st ruc tur e hig hlig ht
ed that the main limitat
io n was staff sho rtag es. W ith r eg ar d t o p ro cess, 60% o f the n ur ses ha d not r ec ei ve d t raining f or car e a ct io ns and o ve r 60% r ep or te d that c ons ultat io ns o ve r the last thr ee mo nths w er e not r ec or de d on the c hildr en ’s health car ds. 75% o f car e d eli ve ry was base d o n c linical p rot oc ols. T he finding s sho w a la ck o f c onsolidat io n o f de ve lo pme ntal f ol lo w-up in p rimar y health car e se rv ic es. M od es e Gaív a (2013) 43 P rimar y health car e se rv ic es in ur ban and r ur al ar eas St ruc tur e o f c hild car e c ent er s T he r es ults sho w that 61.5% o f the car e c ent er s did not ha ve r ec ep tio n o r wait ing r oo ms. H ow ev er , al l c ent er s ha d n ur se and do ct or c ons ult ing r oo ms, v ac cinat io n r oo ms, and disp ensing ar eas. Sho rtag es o f mat er ials w er e r ep or te d in al l c ent er s. A vailab ilit y of standar d me dicat io ns and SIN AN and SISV AN f or ms was r ep or te d t o b e g oo d. T he finding s sho w ed a la ck o f SIAB f or ms and va ccinat io n car ds. Onl y 53.8% o f the health p ro fessio nals ha d c ompu te rs w ithou t a cc ess t o the int er ne t. T he car e st ruc tur e was not in line w
ith the minim
um standar ds se t b y the M inist ry o f H ealth. c har t 2. R es ults o f the anal ysis o f the ar tic les inc lud ed in the r ev ie w , B elo H or iz ont e, M inas Ge rais, B razil, 2017. it c ont in ues
aúd e C ole tiv a, 25(8):3185-3200, 2020 c har t 2. R es ults o f the anal ysis o f the ar tic les inc lud ed in the r ev ie w , B elo H or iz ont e, M inas Ge rais, B razil, 2017. A u tho r (y ear) ty p e o f se rv ic e ev al uat ed it em e val uat ed Se rv ic e q ualit y indicat or s/ c onc lusio ns M od es e Gaív a (2013) 40 P rimar y health car e se rv ic es C
hild health car
e pr oc esses and ou tc omes W ith r eg ar d t o p ro cess, 60.6% o f c hildr en r ec ei ve d d ev elo pme ntal f ol lo w-up fr om d oc to rs and n ur ses. T he least t est ed par ame te r was b lo od p ress ur e. T he p ro fessio
nals that most use
d the c
hild health car
d ar e n ur ses; ho w ev er , the car ds w er e not fil le d ou t pr op er ly . A round 75.6% o f mothe rs und er st oo d the t opics discusse d w ith the p ro fessio nals and 62.2% r ep or te d that the y ha d the o pp or tunit y t o r aise the ir d oub ts and c onc er ns. T he e val uat io n o f car e q ualit y and health p ro fessio
nals was fair and g
oo d, resp ec ti ve ly . L ev el o f sat isfa ct io n was asso ciat ed w ith guidanc e o n p re ve nt io n o f a ccid ents, v iole nc e, and r espir at or y p ro ble m, the op p or tunit y t o discuss c onc er ns d ur ing the c ons ultat io n, and fr ee-o f-c harg e me dicat io n. Sales e t al. (2013) 15 FHS C hild car e qualit y standar ds re co mme nd ed b y the AIQ T he q ualit y standar ds w er e: e le me ntar y (84.1%), in d ev elo pme nt (69.7%), c onsolidat ed (58.6%), g oo d (82.1%), and a dv anc ed (47.7%). T he finding s d emo nst rat ed that the q ualit y o f c
hild health car
e sho w ed basic d ev elo pme nt patt er ns. T he r es
ults also sho
w
that the health t
eams that ha d b ee n w or king f or less t ime sho w ed the b est r es ults. M ac ha do e t al. (2012) 24 FHS A cc ess, car e and sat isfa ct io n A cc ess to health se rv ic es: 91.1% of c hildr en ha d ha d co ns ultat io ns in the last 6 mo nths; 77.4% use d the health ce nt er closest to the ir ho me; 72.6% r ep or te d an a ve rag e wait ing t ime o f at least tw o hour s; and 51.7% r ec ei ve d v isits fr om a c omm unit y health ag ent. T reat me nt: 74.0% r ep or te d that the ir last c ons ultat io n was w ith a d oc to r; 57.7% kne w the name o f the health p ro fessio nal that sa w the m; and 63.7% o f pr of essio nals cal le d the mothe r/c hild by the ir name. A round tw o-thir ds o f the mothe rs re p or te d be ing sat isfie d w
ith the last c
ons ultat io n. T he main asso ciat ed fa ct or s w er e: the fa ct that the p ro fessio nal cal ls the mothe r/c hild by the ir name; same-da y c ons ultat io n; and p ro visio n o f e nt er tainme nt f or c hildr en in the wait ing r oo m. One o f the st re ngths o f the se rv ic es hig hlig ht ed b y the st ud y was ease o f a cc ess t o se rv ic es. W eaknesses inc lud ed the a do pt io n o f a cur at iv e car e mo de l, w ith little e mp hasis o n health p ro mot io n and disease p re ve nt io n. S er vic e use r sat isfa ct io n was asso ciat ed w ith the pat ie nt- health pr of essio nal r elat io nship . Leão e t al. (2011) 22 FHS and othe r child car e se rv ic es P rimar y car e att rib u tes* T he FHS sc or ed hig he r than othe r car e se rv ic es. T he diff er enc es b etw ee n the tw o t yp es o f se rv ic e w er e sig nificant. N eithe r the FHS (6.4)** no r the othe r se rv ic es (5.7)** a chie ve d the q ualit y cu t-o ff sc or e f or “g ene ral it ems ”**. B oth se rv ic es o btaine d lo w sc or es fo r “a cc essib ilit y” , “ av ailab le se rv ic es ”, “famil y c ent er edness ”, and “c omm unit y o rie ntat io n” . T he FHS was the p re fe rr ed se rv ic e f or child car e f or 77.7% o f se rv ic e use rs. Luhm e t al. (2011) 25 P rimar y health car e se rv ic es V ac cinat io n c ov er ag e, pr ofile o f se rv ic e use rs, and u tilizat io n of p rimar y car e se rv ic es C hild v ac cinat io n c ov er ag e r ang ed fr om 95.3% at ag e 12 mo nths t o 90.3% at ag e 24 mo nths. A round 98% o f the imm unizat io n re co rds w er e c ompu te riz ed. T he d ose und er re po rt ing and d uplicat io n r at e was 11% and 20.6%, r esp ec ti ve ly . C ov er ag e was g reat er amo ng c hildr en p er mane ntl y r eg ist er ed in the se rv ic es and those w ho ha d ha d 3 o r mo re c ons ultat io ns, and in c ent er s w ith co mple te health t eams. V ac cinat io n c ov er ag e was hig h and e ve n. A ffiliat io n w ith se rv ic es was an imp or tant fa ct or in a chie ving these r es ults. it c ont in ues
Sil c har t 2. R es ults o f the anal ysis o f the ar tic les inc lud ed in the r ev ie w , B elo H or iz ont e, M inas Ge rais, B razil, 2017. A u tho r (y ear) ty p e o f se rv ic e ev al uat ed it em e val uat ed Se rv ic e q ualit y indicat or s/ c onc lusio ns Leão e Cald eir a (2011) 44 FHS A sso ciat io n b etw ee n pr imar y car e att rib u
tes* and the
qualificat io n o f FHS do ct or s and n ur ses T he finding s sho w that health t eams w ith p ro fessio nals w ho ha d d one famil y health o r famil y and c omm unit y me dicine r esid encies ob taine d hig he r p rimar y car e att rib u te sc or es. C osta e t al. (2011) 17 FHS St ruc tur e, p ro cess, and ou tc ome do mains C ar e qualit y was fair f or al l d omains. W ith re gar d t o st ruc tur e, the st ud y hig hlig ht ed limitat io ns in ph ysical fa cilit ies, mat er ial sho rtag es, la ck of p rot oc ols, amo ng othe rs. W ith re gar d to pr oc ess, the finding s hig hlig ht that car e was limit ed and fr ag me nt ed, a f ocus o n cur at iv e car e, and ina de quat e tr aining fo r health p ro mot io n and disease pr ev ent io n. T he finding s also hig hlig ht ed ad vanc es in re ce pt iv eness, limitat io ns w ith re gar d to the de ve lo pme nt of health pr omot io n and disease pr ev ent io n, and ad vanc es in the r eo rg anizat io n o f c hild car e. R ib eir o e t al. (2010) 41 FHS R ec ep ti ve ness o f child p rimar y health car e T he finding s sho
w that the FHS was the p
re fe rr ed se rv ic e f or c hild car e f or 77.6% o f r esp ond ents, p rincipal ly d ue t o the pat ie nt-health car e p ro fessio nal r elat io nship . W ith r esp ec t t o r ec ep ti ve ness, 74.2% o f se rv ic e use rs r ep or te d that the y b elie ve d that the pr of essio nals und er st oo d w hat the
y said and ask
ed; 79.2% r esp ond ed q uest io ns a cc or ding t o the ir und er standing; 77.2% w er e ab le to talk t o the p ro fessio nals w he ne ve r the y ne ed ed t o; and 73,2% f elt c omf or tab le talking t o the p ro fessio nals. R ec ep ti ve ness was co nsid er ed sat isfa ct or y. C ald eir a e t al. (2010) 23 FHS and tradit io nal car e cen ter s C
hild health car
e pr oc ess FHS c ent er s sc or ed hig he r f or al l v ar iab les. D espit e p er fo rming b ett er than othe r se rv ic es, the car e FHS se rv ic es w er e ina de quat e in t er ms o f p ro visio n, q ualit y, and ne w se rv ic es. Figue ir as e t al. (2003) 27 FHS and tradit io nal car e cen ter s K no w le dg e and pr ac tic e o f c hild de ve lo pme ntal sur ve illanc e amo ng pr of essio nals D oc to rs and n ur ses w or king in t ra dit io nal health c ent er s ha d b ett er kno w le dg e o f c hild d ev elo pme ntal s ur ve illanc e than those in FHS c ent er s. W ith r esp ec t t o p ra ct ic es, o nl y 21.8% o f mothe rs r ep or te d ha ving b ee n ask ed ab ou t the d ev elo pme nt o f the ir childr en, 27.6% stat ed that the pr of essio nal ha d ask ed ab ou t or obse rv ed the ir child’ s d ev elo pme nt, and 14.4% ha d re ce iv ed guidanc e on ho w to st im ulat e the ir child. T he st ud y co nc lud es that pr imar y car e pr of essio nals ar e not ad eq uat el y tr aine d fo r child de ve lo pme ntal s ur ve illanc e, meaning that s ur ve illanc e is not car rie d ou t sat isfa ct or ily . *P rimar y car e att rib u tes p ro p ose d b y Starfie ld45; **P rimar y health car e att rib u te sc or e base d o n the PCA T -CE a dap te d and v alidat ed f or use in B razil;***Qualit y cu t-o ff sc or e p ro pose d b y the PCA T -CE is 6.6 - sc or es eq ual t o o r g reat er than the cu t-o ff indicat e st ro ng o p er at io nalizat io n o f the att rib u te, w hile sc or es lo w er than the cu t-o ff indicat e w eak o p er at io nalizat io n; FHS (F amil y H ealth St rat eg y); SIN AN (B razil’ s not ifiab le diseases inf or mat io n sy st em); SISV AN (B razil’ s n u tr it io n s ur ve illanc e sy st em); SIAB (B razil’ s p rimar y car e inf or mat io n sy st em); AIQ = A ssessme nt f or I mp ro
ving the Qualit
y o f the F amil y H ealth St rat eg y; PCA T -CE = P rimar y C ar e A ssessme nt T ool C hild Edit io n.
aúd e C ole tiv a, 25(8):3185-3200, 2020
Although studies frequently highlighted the strength of affiliation with the FHS, geographic barriers, lack of adequate service structure, staff shortages, underprovision of care, appointment scheduling problems, and long wait times were shown to be major obstacles to improving access to high quality health services37. These obstacles
also affect child health indicators, highlighted as one of the main challenges of the PNAISC2.
Lack of family and community centeredness was one of the most common limitations cited by the literature22,38, suggesting that care is centered
on the individual, with little emphasis on patient contextual factors. Social disadvantage, poor hy-giene habits, unhealthy environments, and family violence are just some factors that adversely affect child health and therefore increase the demand for care services. The lack of health promotion and disease prevention actions culminates in not only increased demand for health services, but also a reduction in quality of care delivery39,40. In this
respect, training of care professionals is a decisive factor in tackling determinants of child health such as the domestic environment, family life, and ante-natal care and care throughout labor and birth2.
The quality of the patient-health care profes-sional relationship, which encompasses access to health workers and information, the fact that pa-tients know the professionals, receptiveness, and forming bonds with patients, was highlighted as a positive point16,23,41. Improving the quality of
the patient-health care professional relationship is one of the pillars of quality primary health care and one of the guidelines of the PNAISC2,23 and,
despite the organizational and structural chal-lenges faced by the FHS, important strides have been taken in this direction.
One of the limitations of this study is the fact that screening for methodological quality was performed by only one reviewer; however, we ad-opted a rigorous study methodology, following the PRISMA statement for reporting systematic reviews and the STROBE and SRQR guidelines.
conclusion
The findings show that the highest-scoring pri-mary care attributes were strength of affiliation and the patient-health care professional rela-tionship. Furthermore, despite the expansion of the FHS, accessibility remains a major obstacle to securing the necessary improvements in care quality. The lack of family centeredness and community orientation underscores the need for adequate staff training, extending the challenge beyond policy makers to include education insti-tutions. In this respect, the latter need to priori-tize the training of health professionals who have the necessary knowledge, practical skills, and commitment to strengthen primary health care.
Future research should investigate contexts outside the South and Southeast regions, focus-ing on vulnerable populations and more eco-nomically disadvantaged areas where it is diffi-cult to attract and retain health workers, in order to help identify and respond to the challenges in improving primary child health care in Brazil.
Sil
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Article submitted 04/03/2018 Approved 27/11/2018
Final version submitted 29/11/2018
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