FAMI LY PERSPECTI VE ON A FAMI LY CARE PROGRAM
Helena Er i Shim izu1 Car los Rosales2
Shim izu HE, Rosales C. Fam ily per spect ive on a fam ily car e pr ogram . Rev Lat in am Enfer m agem 2008 set em br
o-out ubr o; 1 6 ( 5 ) : 8 8 3 - 8 .
Th is st u dy aim ed at assessin g t h e f am ily ’s per spect iv e on a f am ily car e pr ogr am t o bet t er u n der st an d t h e challenges and pot ent ial capacit ies for changing t he healt h car e m odel. A qualit at iv e st udy w as car r ied out t o assess t h e Fam ily Healt h Pr ogr am in t h e cit y of São Sebast ião, Br asília, Br azil. Dat a w as collect ed t h r ou gh dir ect sy st em at ic obser v at ion s of t h e w or k flow dev eloped by t h e pr ogr am ’s t eam , an d t h r ou gh focal gr ou ps w it h fam ily m em ber s. The discour se of t he collect ive subj ect w as used in dat a analysis and show ed t hat healt h p r ev en t ion an d p r om ot ion act ion s an d t h e r elat ion sh ip b et w een p r ov id er s an d con su m er s w er e p osit iv ely evaluat ed w hile access t o healt h ser vices, dr ugs and pr ovider s w as negat ively evaluat ed. Ther e is no assur ance of com pr ehensiv e and cont inuous car e t o t he fam ily , w hich point s t o t he need of r ev iew ing t he st r at egies of healt h ser v ice or ganizat ion for m or e effect iv e inv olv em ent of t he com m unit y t o m eet t heir healt h needs.
DESCRI PTORS: pr im ar y healt h car e; fam ily healt h; consum er sat isfact ion
LA ATEN CI ÓN A LA SALUD DE LA FAMI LI A EVALUADA POR EL PROPI O USUARI O
Est e est udio t iene com o obj et iv o analizar la ev aluación del usuar io sobr e la at ención a la salud de la fam ilia, con la f in alid ad de v er if icar las dif icu lt ad es y p ot en cialidades par a t r an sf or m ar el m odelo de at en ción a la salu d. Se t r at a de u n est u dio de caso cu alit at iv o, r ealizado en u n a Un idad de Salu d de la Fam ilia, en San Sebast ián , Br asilia- DF, Br asil, cu y a r ecolección de dat os con sist ió en la obser v ación del pr oceso de t r abaj o desar r ollado por el equipo y gr upos focales con usuar ios. Los dat os analizados, ut ilizando la t écnica del Discur so del Su j et o Colect iv o, dem ost r ar on qu e las accion es de pr ev en ción y pr om oción de la salu d y la r elación de pr ofesionales y usuar ios fuer on evaluadas posit ivam ent e; y, el acceso a los ser vicios de salud, a los m edicam ent os y a los pr ofesionales fue evaluado negat ivam ent e. Las acciones desar r olladas no gar ant izan la at ención int egr al de la salud de la fam ilia y señalan la necesidad de r ev isar las est r at egias de or ganización del ser v icio, sobr e t odo las que posibilit en la par t icipación de la com unidad par a r esolv er sus necesidades.
DESCRI PTORES: at ención pr im ar ia de salud; salud de la fam ilia; sat isfacción de los consum idor es
A ATEN ÇÃO À SAÚDE DA FAMÍ LI A SOB A ÓTI CA DO USUÁRI O
Est e est u d o t ev e com o ob j et iv o an alisar a ót ica d o u su ár io sob r e a at en ção à saú d e d a f am ília, a f im d e v er ificar as dificuldades e pot encialidades par a a t r ansfor m ação do m odelo de at enção à saúde. Tr at a- se de est udo de caso qualit at iv o, r ealizado em um a Unidade de Saúde da Fam ília, a de São Sebast ião, Br asília, DF, cu j a colet a d e d ad os con sist iu d a ob ser v ação d o p r ocesso d e t r ab alh o d esen v olv id o p ela eq u ip e e g r u p os focais com usuár ios. Os dados analisados, ut ilizando- se a t écnica de Discur so do Suj eit o Colet ivo, dem onst r ar am que as ações de pr ev enção e pr om oção da saúde e a r elação pr ofissionais- usuár ios foi av aliada posit iv am ent e e o acesso aos ser v iços de saúde, aos m edicam ent os e aos pr ofissionais for am av aliados negat iv am ent e. As ações desenvolvidas não gar ant em a int egr alidade da at enção à saúde da fam ília e apont am par a a necessidade de se r ev er em as est r at égias de or ganização do ser v iço, sobr et udo aquelas que possibilit em a par t icipação da com u n idade par a o alcan ce de su as n ecessidades.
DESCRI TORES: at enção pr im ár ia à saúde; saúde da fam ília; sat isfação dos consum idor es
1
Adj unct Pr ofessor, Facult y of Healt h Sciences, Univer sit y of Br asília, Brazil, e- m ail: shim izu@unb.br ; 2 Regional Advisor, Hum an Resour ces for Healt h Unit , Panam er ican Healt h Or ganizat ion, Washingt on, DC, Unit ed St at es, e- m ail: r osalessc@paho.or g.
I NTRODUCTI ON
T
he Fam ily Healt h St rat egy ( ESF) is a priorit y appr oach for t he r eor ganizat ion of pr im ar y car e basedo n t h e B r a z i l i a n N a t i o n a l H e a l t h S y s t e m ( S US )
principles. This st rat egy should be im plem ent ed using
m anagem ent and healt h pr act ices t hat ar e equit able
a n d i n v o l v e t h e c o m m u n i t y, p r o v i d e d b y a
m u lt id iscip lin ar y t eam an d d eliv er ed t o p op u lat ion s
in defined linked areas w it h t he use of highly effect ive
an d com p lex , low - d en sit y t ech n olog ies( 1 ). I t sh ou ld b e i n t eg r a t ed t o a n et w o r k o f ser v i ces t o a ssu r e
com pr ehensiv e car e t o indiv iduals and t heir fam ilies
an d p r ov id e r ef er r al an d cou n t er - r ef er r al f r om t h e
pr im ar y care level t o m ore com plex levels of at t ent ion.
I n t h e Fed er al Dist r ict , Br asília, t h e Fam ily
Healt h St r at eg y is cu r r en t ly k n ow n as t h e Healt h y
Fam ily Pr ogram ( in Por t uguese, PFS) . Ten year s aft er
it s im plem ent at ion, as seen nat ionw ide, PFS has been
m eet ing significant challenges locally. Difficult access
t o c a r e , d i s c o n t i n u e d a t t e n t i o n a n d l a c k o f
com pr ehensive car e ar e som e of t he pr oblem s faced,
callin g f or a p r of ou n d r eev alu at ion of t h is com p lex
pr ogr am( 2 - 4 ).
I t is t hus crucial t o evaluat e t he PFS as part
o f a p r o ce ss o f cr i t i ca l l y a sse ssi n g t h e se r v i ce s
pr ov ided based on t h e par t icipat ion of t h e in v olv ed
act or s, especially t h ose u ser s w h o can m or e clear ly
and reliably art iculat e t heir opinions on care delivered
t o t hem( 2, 5- 9). I n t his sense, t he ev aluat ion m ade by t h e v er y p op u lat ion at t en d ed b y PSF t eam aim s at
pr ov idin g in pu t f or r et h in k in g pr of ession al pr act ices
an d i m p l em en t i n g act i on s f or t h e i m p r ov em en t of
ser v ice or g an izat ion .
St u dies as su ch h av e in cor por at ed in t o t h e
evaluat ion process a subj ect ive dim ension t hat allow s
t o assessing qualit y of PSF ser v ices, including user ’s
sat isf act ion assessm en t( 6 - 9 ). How ev er, it sh ou ld b e not ed t hat m ost st udies have adopt ed m echanist and
f u n ct ion alist appr oach es, ov er look in g pr ior it y issu es
for ser v ice ev aluat ion( 7- 9).
Ack n o w l e d g i n g t h e se l i m i t a t i o n s a n d t h e
special need t o br oaden t he analy ses and go bey ond
t h e sim p le ap p r aisal of PSF u ser ’s sat isf act ion , an
ev a l u a t i o n p r o cess h a s b een p r o p o sed t o ex p l o r e
cult ur al and behav ior al changes: representations of the
healt h- disease process, appropriat e care pract ices and
health m anagem ent strategies(8-9). Also, it should further exam ine t he m eaning of fam ily, which is regarded as a
social agent of change from a wider perspective.
Hence, t his ev aluat ion should allow user s t o
act u ally ex pr essin g t h eir su bj ect iv e v iew s abou t t h e
care service( 7- 11), giving t hem an oppor t unit y t o fr eely discu ss t h eir feelin gs an d per cept ion s abou t sev er al
d i f f er en t d i m en si o n s: g en er al n eed s ( d ef i ci en ci es,
h e a l t h - r e l a t e d n e ce ssi t i e s) ; co g n i t i v e ( p e r ce p t i o n
ab o u t car e ser v i ce) ; r el at i o n al ( r esp ect , l i st en i n g ,
r ecept ion) ; or ganizat ional ( access t o ser v ices, dr ugs,
p r o v i d e r s ) ; a n d p r o f e s s i o n a l ( q u a l i t y a n d
com pet en ce)( 8 - 9 ).
Th e p u r p o se o f t h e p r esen t st u d y w a s t o
p r o v i d e i n p u t t o c o n s i d e r t h e i n c l u s i o n o f u s e r
subj ect ivit y in t he assessm ent of healt h service qualit y
a n d t o e x a m i n e f a m i l y c a r e f r o m t h e u s e r ’ s
perspect ive t o ident ify crit ical challenges and pot ent ial
c a p a c i t i e s f o r i m p r o v i n g c a r e a n d u l t i m a t e l y
r eor gan izin g t h e car e m odel.
USER SATI SFACTI ON: A BRI EF REVI EW
Since 1960s in Eur ope and t he US and m
id-1990s in Br azil, user sat isfact ion appr oach has been
applied in healt h evaluat ion st udies( 12- 13). This appr oach focuses on t he different dim ensions involved in healt h
car e, fr om doct or - pat ien t r elat ion sh ip t o t h e qu alit y
of facilit ies and car e deliv er ed by healt h pr ov ider s.
The concept of qualit y has enabled t o bet t er
define m easur em ent v ar iables of ser v ice qualit y w it h
t he inclusion of a non- specialized out look; i.e., user s’
view( 13). Sever al m odels have been designed for user sat isf act ion assessm en t an d m ost ar e based on t h e
a ssu m p t i o n s o f u ser p er cep t i o n s co n cer n i n g t h ei r
e x p e ct a t i o n s, v a l u e s a n d n e e d s a t t h e d i f f e r e n t
dim ensions of healt h car e( 12- 13).
Wh en f or m in g t h eir opin ion abou t ser v ices,
u s e r s t a k e i n t o c o n s i d e r a t i o n o n e o r m o r e
c o m b i n a t i o n s o f t h e f o l l o w i n g a s p e c t s : a n i d e a l
ser vice; a not ion of car e ser vice t hey ought t o have;
t h e i r p a st e x p e r i e n ce s i n si m i l a r se r v i ce s; a n d a
m i n i m u m su b j ect i v e l ev el o f ser v i ce q u al i t y t o b e
achiev ed t o be accept able( 12- 13).
Recognizing t he inher ent com plexit y of user ’s
assessm ent process of service qualit y, t he World Healt h
Or g an izat ion ( WHO) in t r od u ced a su r r og at e f or t h e
concept of sat isfact ion: r esponsiveness. This pr oposed
concept int ends t o exam ine how gover nm ent al act ions
m eet p eop le’s ex p ect at ion s an d d em an d s( 1 2 ) an d is based on t he assum pt ion t hat healt h sy st em s should
pr om ot e and m aint ain people’s healt h, t r eat t hem w it h
d ig n it y an d f acilit at e t h eir in v olv em en t in d ecision
m ak in g r eg ar d in g t h eir h ealt h car e, t r eat m en t an d
Mor e r ecen t ly, du e t o a con cer n t o act u ally
t ake int o considerat ion users’ st at us in healt h services
and syst em s and, m or e im por t ant ly, t o allow t hem t o
expr ess t heir st at us, t he concept of hum anizat ion w as
in clu ded in t h e design of h ealt h ser v ices ev alu at ion
s t u d i e s( 1 0 - 1 2 ). Th i s c o n c e p t f o c u s e s o n h u m a n , indiv idual and et hical dim ensions of car e and user ’s
r ight s and em pow er m ent . Alt hough new and not y et
st rong, t his proposal calls for t he inclusion of a healt
h-r elat ed social/ cu lt u h-r al d im en sion in t h e ev alu at ion
pr ocess, especially in qualit at iv e st udies.
METHODS
I t w as opt ed t o con du ct a qu alit at iv e st u dy
as it allow s cap t u r in g su b j ect s’ p er cep t ion s, b elief s
a n d v a l u e s o n a n a r r a y o f s i t u a t i o n s r o u t i n e l y
ex per ien ced at PSF. Th e PFS u n it in t h e cit y of São
Sebast ião, Feder al Dist r ict , w as st udied since it m et
t he inclusion cr it er ia: lar ge st aff in t he m et r opolit an
ar ea; at least six m ont hs of oper at ion; and pr im ar y
car e t eam av ailab le ( on e d oct or, on e n u r se, t h r ee
nur sing assist ant s and fiv e healt h w or k er s) .
A t w o- st ep d at a collect ed w as car r ied ou t .
First , dat a w as collect ed from a focus group discussion.
Th er e w er e t w o session s, on av er ag e an h ou r an d
half each, w her e a coor dinat or and an obser v er m et
w it h m em ber s of 1 0 fam ilies w h o at t en ded t h e PSF
f or at least a y ear an d liv ed in t h e f iv e m icr oar eas
st u died. Th e f ocu s gr ou p par t icipan t s w er e select ed
by dr aw ing and had t he follow ing pr ofile: 60% w er e
fem ales, 40% m ales; 50% had com plet e and 50% had
i n c o m p l e t e e l e m e n t a r y s c h o o l i n g ; 6 0 % w e r e
hom em akers, 30% unem ployed and 10% were ret ired.
Th e f o cu s g r o u p d i scu ssi o n s w e r e g u i d e d
based on t he follow ing st at em ent s: “ Tell us how you
per ceiv e t h e PFS” ; an d “ Tell u s abou t t h e pr os an d
con s of car e pr ov ided at t h e PFS”. Th e discou r se of
t he collect iv e subj ect ( DCS) appr oach w as applied in
t he analysis( 14). Key expr essions of cent r al ideas w er e fir st ident ified in each speech and t hen cent r al ideas
w er e singled out and gr ouped. Each gr oup w as nam ed
and a sum m ar y cent r al idea was designat ed. Finally,
DCS w er e const r uct ed for each gr oup as show n above.
Th e secon d st ep of dat a collect ion in clu ded
n o n - p a r t i ci p a n t o b se r v a t i o n o f t h e w o r k p r o ce ss
dev eloped at t he PSF unit . Tw o t r ained inv est igat or s
collect ed t he dat a and r ecor ded it on a log book.
The follow ing aspect s w er e obser v ed ov er a
t w o - w e e k p e r i o d ( 3 0 h o u r s ) : u s e r ’ s r e c e p t i o n ,
scr een in g , m ed ical an d n u r sin g v isit s, p r oced u r es,
hom e visit s, cam paigns and educat ional lect ur es. Over
t h e f ir st w eek , t h er e w er e 2 0 h ou r s of obser v at ion
( m or ning and aft er noon) , and over t he second w eek,
1 0 h o u r s ( m o r n i n g a n d a f t e r n o o n ) . Th e s t u d y
invest igat or s deem ed t his am ount of obser vat ion t im e
sufficient as it pr ovided infor m at ion on how t he w or k
w as dev eloped at t hat ser v ice.
This st ep w as int ended t o assess t he qualit y
of car e, t he r elat ionship bet w een pr ovider s and user s,
a c c e s s t o c a r e s e r v i c e a n d m a n a g e m e n t
effect iv en ess. To fu r t h er ex plor e t h e r ealit y of car e,
i. e., PSF ev er y d ay op er at ion , t h is d at a w as cr
oss-ex am in ed w it h DCS.
Th e s t u d y w a s a p p r o v e d b y t h e Fe d e r a l
Dist r ict Local Healt h Depar t m ent ( SES/ DF) Resear ch
Et h i cs Co m m i t t e e a n d a l l su b j e ct s si g n e d a f r e e
infor m ed consent for m aft er t he obj ect ives, m et hods,
r isk s and benefit s of t he st udy w er e discussed.
RESULTS AND DI SCUSSI ON
DCS 1 show ed t hat user s, w hen r efer r ing t o
PFS, fir st focused on t he healt h r epr esent at ion. This
represent at ion should be w ell underst ood as it guides
user s’ at t it udes and pr act ices t ow ar d healt h car e( 8- 9).
Healt h com es fir st . I f you have good healt h, you sleep
w ell, get up in t he m or ning feeling good, and eat w ell. Healt h is
not having body pain or headaches, is having a healt hy body, it is
not get t ing t oo t ired and feeling w ell for w ork. Healt h is w ealt h. I t
does not m ean only doct ors and drugs. You have t o be concerned
about your eating, cleaning your house and your children. (DCS 1)
This discour se r eveals t hat user s have sought
t o i n cor p or at e i n t o t h ei r l i f e t h e b r oad en ed ,
SUS-pr oposed concept of healt h as a com ponent of qualit y
of life. Healt h is not only underst ood as an absence of
d i s e a s e s , a l o n g - l a s t i n g c o n c e p t t h a t g e n e r a l l y
int ended t o keep a healt hy, pr oduct ive body. The WHO,
in an effor t t o br oaden t he under st anding of healt h,
h a s p r o p o se d t h e co n ce p t o f h e a l t h a s co m p l e t e
physical, m ent al and social w ell- being. But t his concept
h as b een lar g ely cr it icized f or n ot con sid er in g it a
p r o c e s s i n v o l v i n g e c o n o m i c , s o c i a l a n d c u l t u r a l
f act or s.
I n f act , w h i l e h eal t h p r o v i d er s h av e b een
pr om ot ing a change in t he w ay people t ak e car e of
t heir healt h, m any effort s st ill focus on t he biom edical
m odel w it h a st r ong m echanist or at m ost sy st em ic
e m p h a s i s t h a t a f f e c t s h e a l t h p r a c t i c e( 1 5 ). S u c h a p p r o a ch e s f a i l t o f a ci l i t a t e t h e co m p l e x h u m a n
Ther e is a need t o advance act ions of healt h
pr ev ent ion and pr om ot ion as w ell as t o r einfor ce t he
idea of healt h as a social right based on t he ut ilizat ion
of all t ech n olog ies av ailab le f or h ealt h p r ev en t ion ,
pr om ot ion, t r eat m ent and r ehabilit at ion( 16).
DCS 2 illu st r at ed t h e fam ily r epr esen t at ion ,
w hich is t he m ain goal of PFS t eam w or k.
The fam ily is t he beginning of life and it com pr ises
childr en, par ent s and siblings. I t is a pr ior it y and sym bolizes it
all. I believe t hat if you have a fam ily, you have love and harm ony
wit h t he ot hers. The fam ily is a whole, it gives you love, affect ion,
and car e. I t also can give you a bet t er life. The fam ily com es t o
your r escue dur ing har d t im es, and helps you w hen you find
your self in a pr edicam ent and having a disease. We have t o
com m unicat e w it h each ot her and if w e have ot her pr oblem s, w e
have t o for get t hem . ( DCS 2)
User s descr ibed t h e f am ily as a cor e social
inst it ut ion t r adit ionally for m ed by a fat her, a m ot her
and childr en and it s r ole is t o pr ov ide affect ion, car e
an d h elp t o it s m em b er s. How ev er, it h as ch an g ed
du e t o r ecen t t r en ds of r edu ced f am ily size, f r agile
m ar it al bonds and m ult iple ar r angem ent s ot her t han
t hat of t he convent ional nuclear fam ily. This is above
all a result of single- parent fam ilies com m only headed
by single w om en. These t r ends have r aised quest ions
a b o u t t h e cen t r a l i t y a n d f u t u r e o f t h e f a m i l i es i n
m oder n societ ies as w ell as t heir r esponsibilit ies and
social r oles.
Fo cu si n g o n t h e f a m i l y i s a b r ea k t h r o u g h
t ow ar d ch an gin g t h e h ealt h car e m odel. Yet it calls
t h a t p r o v i d e r s t a k e a n i n - d e p t h , c o n t e x t u a l i z e d
appr oach. To begin w it h, fam ily should not be r egar ded
a s a b i o l o g i ca l , n a t u r a l o r se t b o d y b u t r a t h e r a
pr oduct of hist or ical for m s of hum an or ganizat ion. I n
ad d it ion , t h e f am ily can b e ap p r oach ed in m u lt ip le
w a y s a n d t h e h e a l t h t e a m s h o u l d f i n d t h e b e s t
appr oach t h at w ill allow t h em t o t ak e on r oles t h at
c a n c o m m u n i c a t e w i t h e a c h o t h e r a n d b e
com plem ent ar y t o pr oduce a com pr ehensiv e car e( 17). User s ev idenced t heir r epr esent at ions about
PFS t eam pr ov ider s in DCS 3:
The healt h t eam is also our fam ily because t hey help
us when we find ourselves in a predicam ent . Nursing st aff provide
us m edicines, car e, and cleans us and t akes us t o t he t oilet . This
is all ver y im por t ant . How ever , t her e is god, t her e is t he fam ily
and t here is t he doct or. The doct or is act ually m ade by god; when
you hand it t o t he doct or , you act ually do so quit e know ingly
because he st udied for t hat . ( DCS 3)
User s h a v e q u i t e p o si t i v el y ev a l u a t ed t h e
healt h t eam and in par t icular show an affect ive bond
becau se t h ey r ealize t h ey can cou n t on t h e t eam ’s
h elp. Th e n u r sin g t eam is r egar ded as a car et ak er ;
t he doct or is consider ed m ade by god, i.e., som eone
gift ed t o save lives and w ho has know ledge t o m anage
h ealt h pr oblem s.
Th e r ep r esen t at ion of t h e d oct or as a k ey
e l e m e n t f o r m a n a g i n g p r o b l e m s i s b a se d o n t h e
h eg em o n i c m ed i cal m o d el . I t m ak es i t d i f f i cu l t t o
accept com m on know ledge, w hich is vit al t o pr om ot e
t he fam ily r ole in healt h car e t hr ough pr act ices t hat
do not inv olv e m edicalizat ion.
DCS 4 addr esses t he ev aluat ion of pr act ices
dev eloped by PFS t eam :
We com e her e w hen w e have br onchit is, for t est ing,
checking blood pr essur e, pr event ion. Her e t hey can cur e flu, a
sm all condit ion but w hen t he pr oblem is m or e ser ious, t hey send
you t o a hospit al. That t eam t hat com es t o your hom e t hey visit
t hose who are in m ore need, t hey always com e when it is serious,
t hey have never com e t o m y hom e. Doct or s, nur ses and healt h
w or ker s pay you a visit . The doct or has not been paying visit s
lat ely as he is quit e busy. Yet t he t im es t hey cam e t o m y hom e,
it was very good, it was great for m e. The t eam also gives lect ures,
t hey gave explanat ions, show ed a m ovie. I liked it because t hey
gave a lot of det ails. Anot her act ivit y developed w as t he pr ost at e
cam paign, I enj oyed it ver y m uch. ( DCS 4)
I n r egar d t o t he w or k dev eloped at t he PSF
u n i t , D CS 4 e v i d e n c e s i t i s i n t e n d e d t o t h e
m an ag em en t of low - t ech n olog y m ed ical con d it ion s.
Dur ing t he st udy obser v at ion it w as v er ified t hat t he
w or k t eam spends m ost of it s t im e in int er nal m edicine,
p r en at al, g r ow t h an d d ev elop m en t v isit s w h ich ar e
pr esch edu led an d or gan ized on fr ee dem an d. Th ese
visit s ar e shor t , last ing no m or e t han 15 m inut es, and
f ocu s on com p lain t s w it h lit t le r oom f or d iscu ssion
bet w een user s and pr ovider s. Besides, t her e ar e also
gr oups of high blood pr essur e and diabet es pat ient s
w h o h av e an oppor t u n it y of u n der goin g pr ocedu r es
f or disease m an agem en t .
Hom e visit s, par t icular ly paid t o t hose pat ient s
w it h special needs, w er e posit iv ely ev aluat ed. I t w as
obser ved t hat healt h w or ker s pay hom e visit s, ident ify
fam ily pr oblem s and t hen discuss t hem w it h t he t eam .
They ar e w elcom e in t he com m unit y and people t ell
t hem t heir problem s and seek clarificat ion about t heir
ca r e.
User s also posit iv ely ev aluat ed lect ur es and
d i sea se p r ev en t i o n ca m p a i g n s. I t w a s f o u n d t h a t
l ect u r es a d d r essi n g h y g i en e ca r e, h ea l t h y ea t i n g ,
envir onm ent and w ast e m anagem ent , fam ily planning
an d n ew bor n car e ar e deliv er ed in sim ple lan gu age
but at t endance is low and educat ional r esour ces ar e
pr ev en t ion cam paign s sin ce t h ey per ceiv ed it as an
im por t ant oppor t unit y of healt h m anagem ent .
These findings indicat e t hat PSF act ions aim
at m anaging healt h problem s wit h low t echnology; t hey
t ake m ost of t he providers’ t im e, especially t he doct or’s;
and t here are also educat ional and group m anagem ent
act iv it ies, w h ich ar e h igh ly im por t an t f or im pr ov in g
p r i m ar y car e. Ho w ev er, i t b eco m es cl ear t h at , f o r
im pr ov ing car e qualit y, qualit y act ions w it h effect ive
involvem ent of users and based on t he assessm ent of
t heir act ual needs and dem ands ar e r equir ed.
I n D CS 5 u se r s p o i n t e d o u t f l a w s i n t h e
p r og r am or g an izat ion :
Her e at PSF w e ar e not seen on t he sam e day but w e
m ake an appoint m ent t o be seen lat er . But t her e is a pr oblem , if
you ar e dying and do not have an appoint m ent , you w ill not be
seen. PSF’s m aj or flaw is shor t age of dr ugs. The gover nm ent
usually issues a not ice infor m ing t hat dr ugs ar e available but
when you get t o t he unit you do not get any drugs, you t ry and t ry
but you end up buying at t he phar m acy. I t does not help t o be
seen and do not get any drugs, we get only part of t he t reat m ent .
Anot her huge problem is t o get t est result s. Blood t est result s are
not available because t he equipm ent is out of order, it cannot be
so. Also, PSF healt h t eam does not m anage it all, t hey are so few t o
at t end so m any users and t hey do not have t he required resources
for t heir work. We need a hospit al t o im prove healt h ( DCS 5) .
Wit h r espect t o pr ogr am or ganizat ion, it w as
point ed out difficult access t o car e chiefly because of
b u r eau cr acy ob st acles t o g et t o b e seen . Ev er y d ay
about 10 pat ient s w it h scheduled visit s ar e not seen.
Several users had t heir visit s rescheduled for a m ont h
lat er, som e com plained t hey had t o com e for t he t hir d
t im e t o w ait for an opening. A lar ge num ber of user s
also t r ied t o get hom e v isit s and ot her s com plained
of long w ait at t he unit and ot her ser v ices of higher
com p lex it y.
An o t h e r i ssu e p o i n t e d o u t i n D CS 5 w a s
difficult access t o drugs. I t evidences t hat t he Brazilian
Min ist r y of Healt h d r u g aid p r og r am f or p r om ot in g
com pr ehensiv eness has not been adequat ely m eet ing
p eop le’s n eed s.
I n addit ion, DCS 5 show s user s have difficult
access t o t est ing. Appar ent ly t he difficult y t o m anage
healt h condit ions requiring high t echnology has m ade
user s believe t hey need a hospit al in t heir ar ea. This
belief prevent s users from appr eciat ing PSF and healt h
pr event ion and pr om ot ion act ions as w ell. And, last ly,
u ser s r epor t ed difficu lt access t o pr ov ider s as t h er e
w er e t oo m any people t o be seen.
Access t o m an y ser v ices ( v isit s an d t est s)
and drugs is lim it ed. There is a clear need for PFS t o
i m p r o v e t h e p r o g r a m ’ s c o m p r e h e n s i v e n e s s w i t h
s u s t a i n e d c o o r d i n a t i o n o f f a m i l y - r e l a t e d h e a l t h
pr act ices ( not seen at t he unit ) t o ensur e t he r equir ed
deliv er y of cont inuous, global ser v ices and pr ov ider s
and or ganizat ions, all ar t iculat ed in t im e and space.
Co m p r e h e n s i v e c a r e n e c e s s a r i l y r e q u i r e s t h e
i n t e g r a t i o n o f s e r v i c e s t h r o u g h c a r e n e t w o r k s
c o n s i d e r i n g t h e i n t e r d e p e n d e n c e o f a c t o r s a n d
or ganizat ions as t hey do not hav e by t hem selv es all
r esou r ces r eq u ir ed f or m an ag in g u ser s’ con d it ion s
dur ing t heir life cy cles( 18).
D CS 6 f o cu s o n t h e r e l a t i o n sh i p b e t w e e n
pr ov ider s an d u ser s:
I w as w elcom ed at PSF and ver y all ser ved, t hey all
t r eat m e w ell. This t eam is ver y good in w elcom ing and pr oviding
people care, affect ion and at t ent ion. The doct or is excellent , I like
him a lot . I cannot com plain and I appr eciat e a lot t heir car e.
( DCS 6 )
User s r ev ealed t h at t h e t eam pr ov ider s ar e
k i n d an d af f ect i o n at e i n b o t h r ecep t i o n an d car e.
Hu m a n i za t i o n o f ca r e w a s a ssi m i l a t e d a s a co r e
com ponent of w or k. This concept br ings in t he not ion
of d ig n it y an d r esp ect t o h u m an lif e, u n d er scor in g
t h e et h i cal d i m en si o n o f t h e r el at i o n sh i p b et w een
pat ient s and healt h pr ov ider s( 19).
I n DCS 7, user s ex pr essed t heir per cept ions
ab ou t t h e p r og r am b y com p ar in g car e p r ov id ed at
PFS and ot her healt h car e unit s:
I t hought t hat at PSF one w ould be bet t er ser ved t han
in ot her healt h car e unit s but it is even bet t er . I n basic healt h
unit s, you are no one. Som e doct ors see you but do not even look
at our face, t hey do not check your pr essur e, do not put on t he
m et er , t hey j ust w r it e it dow n and send us aw ay. See, I t hought
t hat w as disr espect ful. ( DCS 7)
Use r s r e v e a l PFS t e a m p r o v i d e r s h a v e a
h u m an ized an d car in g at t it u d e, w h ich m ak es t h em
f e e l t r e a t e d w i t h d i g n i t y a n d r e sp e ct . Th e a b o v e
f i n d i n g s i n d i ca t e PFS h a s t h e p o t en t i a l t o en su r e
hum anizat ion of car e by est ablishing a bond bet w een
pr ov ider s an d u ser s.
Th is w as a r ig h t g ain ed as a r esu lt of t h e
p r o cess o f st r en g t h en i n g d em o cr acy an d p eo p l e’ s
e m p o w e r m e n t g r a n t e d i n t h e 1 9 8 8 B r a z i l i a n
Con st it u t ion , w h ich st ip u lat ed t h at h ealt h ser v ices
should pr eser v e people’s aut onom y and ensur e t heir
access t o healt h infor m at ion.
FI NAL CONSI DERATI ONS
The st udy findings show t hat r epr esent at ion
biom edical m odel st ill pr ev ails am ong healt h ser v ices
u ser s. I t ev iden ces a n eed of PFS t o st r on gly focu s
on a br oader con cept of h ealt h , w h ich in clu des t h e
underst anding of basic hum an biological, psychological
and social needs for healt h pr om ot ion.
As for healt h pr act ices developed at PFS, t hey
f o c u s o n t h e m a n a g e m e n t o f h e a l t h c o n d i t i o n s
r equ ir in g low t ech n ology. User s posit iv ely evalu at ed
h ealt h p r ev en t ion an d p r om ot ion act ion s in clu d in g
h o m e v i s i t s , e d u c a t i o n a l l e c t u r e s a n d d i s e a s e
pr ev en t ion cam paign s. Th ese ar e v alu able t ools bu t
m or e cr eat iv e st r at eg ies ar e n eed ed f or im p r ov in g
car e qu alit y.
U s e r s ’ s a t i s f a c t i o n r e g a r d i n g s e r v i c e
or gan izat ion is v er y low , m ost ly becau se of difficu lt
access t o ser v ices, d r u g s an d p r ov id er s, w h ich ar e
k e y f o r h e a l t h m a n a g e m e n t . Ca r e p r o v i d e d w a s
perceived as hum anized, caring and respect ful, w hich
i n d i ca t e d t h a t b o n d s ca n b e d e v e l o p e d b e t w e e n
providers and users as t hey are crucial for fam ily care.
I n conclusion, PSF has m ade som e advances
in fam ily care but it s act ions need t o be redirect ed for
b r in g in g ab ou t ch an g e t o t h e car e m od el, w it h an
effect ive involvem ent of users for m eet ing t heir needs.
Pe o p l e ’ s e m p o w e r m e n t sh o u l d b e so u g h t i n t h e
pr ocess of pr ogr am m an agem en t as a r equ isit e f or
q u a l i t y p o l i c y a n d t e c h n i c a l a c t i o n s a n d t h e
developm ent of a cult ur al ident it y in t he com m unit y,
open in g u p n ew h or izon s f or gain in g t h e r igh t t o a
h ealt h y lif est y le.
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