Community Health Agents Program Research Articles

Héctor Abad-Gómez (1921-1987): médico, educador y defensor de los derechos humanos

Héctor Abad-Gómez, Colombian physician, university professor, journalist and human rights defender, was murdered in Medellín in 1987. He was a pioneer public health activist engaged in various fields. While being student his restless and dissatisfied mind, led him to fight for a better and safer water and food. He specialized in the University of Minnesota (USA), at his return to the country he led the establishment of the Rural Medical Service. Forced to exile for several years he was WHO consultant to several countries in the Americas and Asia. In 1956 he founded the Preventive Medicine and Public Health Department of the University of Antioquia. He carried out the first recorded mass community vaccination against polio in the world. He initiated a community health agents program known as “Rural health promoters” that later would be implemented nationally. In 1962 he first proposed the application of epidemiological methods to study violence; he was visiting professor at the University of California; he coined the term “polyiatry” for a specialty dedicated to the health populations; he was director of the Colombian National School of Public Health that currently bears his name. Héctor Abad-Gómez ventured into political life, in accordance with Virchow dictum that “politics is medicine on a large scale”. The lives of both have interesting similarities except for the tragic and premature death of the former that still receives rejection today in social, political and academic levels, both in Colombia and abroad.

ACESSO E UTILIZAÇÃO DOS SERVIÇOS DE SAÚDE POR QUILOMBOLAS CONTEMPORÂNEOS BAIANOS

Understanding the provision of health services to the black Brazilian population is important. In this sense, the present study aimed to verify how the health services of rural quilombolas in the geographical region of Bahia are accessed and used. It is a population-based survey, with information obtained through the application of standardized questionnaires. Poisson's regression tested the associations. No community had a functioning health service infrastructure and three had no coverage from the Community Health Agents Program. Most quilombola’s indicated home registration at the Basic Health Unit, however, the indication for monthly visits by CHWs was less than the expected. Conversely, the majority cited never having been visited by endemic agents. Hears indication of medical consultation in the last 12 months by the majority, especially among women. The services demanded in the last two weeks were obtained predominantly from public services. Thus, access to and use of health services by quilombolas in the Guanambi / Bahia region occurs unevenly due to structural barriers, limited availability of human resources and local infrastructure.

Performance Evaluation of Community Health Workers: Case Study in the Amazon of Peru.

A shortage in human resources for health is a growing crisis that has led to an inability to provide adequate health services to impoverished populations. By "task-shifting", health systems can delegate certain activities, such as health promotion and referral, to trained community members to help fill the human resource gap. An effective community health agent program can improve maternal and child health and overall effectiveness of rural health systems. Such a program is most effective when the community health agents receive supervision and evaluation of their performance. There is a shortage of literature that provides instruction and example on how to conduct a performance evaluation in the developing world to improve maternal and child health outcomes. The current study provides a case study of a performance evaluation in the Amazon region of Peru and how the findings can be used to make program adjustments. A set of instruments to measure the performance of CHWs was adapted from the literature and then implemented in the field. The instruments were used to measure the quality of home visits by the CHWs, their knowledge of the health topics, and structural activities. Three communities with an active CHW program in Loreto, Peru were chosen to receive the evaluation. All CHWs in the communities were evaluated. The scores from the evaluation were compared internally to identify strengths and weaknesses of the program and within the population of CHWs. The evaluation was completed on 52 home visits and 27 CHWs in three communities. The CHWs were found to be most effective at creating good relationships with caregivers and delivering health messages, and least effective at interacting with the child during the home visit and using material to deliver health messages. The evaluation instruments were well suited for the CHW program that utilizes home visits to teach about child health and development.

MECA: Mobile System Support for Brazilian Community Health Agents Program Based on Context-Awareness

The advance of information systems ascended research in the area of pervasive computing applied to healthcare, especially in the application of context-awareness in pervasive applications. In essence, context-awareness in healthcare integrates concepts and technologies to provide healthcare to a wider part of the population and in a personalized way. Allied to mobile technologies, context-awareness can support healthcare professionals providing pervasive access to information in an adaptable, private and personalized form. This work presents a software architecture, called MECA, to support Brazilian community of health agents program based on context-awareness. This system aims to assist the community of health workers in carrying out the processes of context integration and then, present relevant information to the agent according the actual context, as location, time and activity, among others. Through an evaluation in a study case, it was possible to verify the efficiency of the association of context information in the presentation of information to health agents and the alerting with contextual information, based on precision and recall measure.

Identification of familial clustering for cancer through the family health strategy program in the municipality of Angra dos Reis, Rio de Janeiro, Brazil.

Identification of families with history of cancer in the municipality of Angra dos Reis, Rio de Janeiro (Brazil), through the Brazilian Unified Primary Health Care System was explored based in the Community Health Agents (CHA) program. This study was divided into two phases: a descriptive one with a cross-sectional epidemiological data of families with history of cancer based on CHA-collected data from home visits in four primary health care units. The second phase consisted in identifying familial clustering of three or more individuals with cancer through construction of a three-generation pedigree and revisited by an itinerant group of medical geneticists. Genetic counseling was carried out with the intent of selecting potential families at risk for hereditary familial cancers. In the first phase of the study, 1,581 families were interviewed by the CHA at their homes. A positive history for cancer was present in 42.3% of families, comprising 22.3% with only one case per family, 11.2% with two cases, and 8.6% with three or more cases in the family. The informant reported that 15% of the cases were from the father lineage, 12% from the mother lineage, and 12.1% within siblings. In the remaining 60.9% families, cancer was present in both sides of the family. The types of cancer reported were uterus 8.7% (n = 137), stomach 7.7% (n = 122), breast 6.9% (n = 109), throat 6.8% (n = 99), prostate 5.4% (n = 85), lung 5.6% (n = 88), bowel 3.7% (n = 59), and unspecified sites in 6.8% (n = 108) of families. No statistical differences were noted between the data collected on each primary care unit. In the second phase of the study, 136 families (2.9%) from the total of families interviewed in phase 1 were selected due to the presence of three or more individuals with cancer in the family. Among those, only 73 families attended genetic counseling. Comparison between the data obtained by the CHA and the medical geneticists shows complete agreement in 36 cases (49.3%), partial agreement in 25 cases (34.2%) with more detailed information in the CHA sheets, discordance in 4 cases (5.5%), and not possible to correlate in 8 cases due to identification inconsistency. Risk assessment for cancer was calculated based on the criteria adopted by Scheuner et al. (Genet Med 12(11):726-735, 2010) and revealed that 50.0% of the families were classified as having a weak risk, 36.1% a moderate risk, and 13.8% were considered of high risk. Concerning known hereditary cancer syndromes, we found one family that met the criteria for breast and ovary hereditary cancer (1.4%) and one family with non-polyposis hereditary colon cancer as revised by Bethesda protocol. Such preliminary results indicated that the Brazilian Primary Health Care system based on the CHA framework can be an effective entrance into the Unified Brazilian Health Care System (SUS-Brazil) for individuals with genetically determined diseases, such as familial cancer. Families with a history of three or more cases of cancer and considered of high risk for familial cancer could be referred to a tertiary health center for proper oncogenetic counseling.

Cultura da segurança do paciente na atenção primária à saúde

O objetivo foi analisar as atitudes que evidenciam a cultura da segurança do paciente pelos profissionais das equipes da Estratégia de Saúde da Família e do Programa de Agentes Comunitários de Saúde. Aplicou-se o questionário de Atitudes de Segurança, com 64 perguntas, a uma amostra de 96 profissionais da equipe de enfermagem e agentes comunitários de saúde na cidade de Florianópolis-SC, a fim de avaliar nove atitudes de segurança. As atitudes Cultura do Trabalho em Equipe, Condições de Trabalho, Comunicação e Gerência do Centro de Saúde tiveram p-Valor <0, 05, evidenciando-se como atitudes significativas da cultura da segurança do paciente. Contudo, essas mesmas quatro atitudes de segurança foram avaliadas de forma diferente pelos agentes comunitários de saúde em relação aos enfermeiros e técnicos de enfermagem. Na amostra analisada das três categorias profissionais, a atitude considerada de maior importância foi a Segurança do Paciente, já a variável com menor relevância para essas categorias foi a atitude Erro.

Analysis of the evolution and determinants of income-related inequalities in the Brazilian health system, 1998 - 2008

To analyze the evolution and determinants of income-related inequalities in the Brazilian health system between 1998 and 2008. Data from the National Household Sampling Surveys of 1998, 2003, and 2008 were used to analyze inequalities in health and health care. Health was measured by self-reported health status, physical limitations, and chronic illness. Hospitalization and physician and dentist visits were proxies for health care utilization. Income was a proxy for socioeconomic status. Concentration indices were calculated before and after standardization for all dependent variables. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. In all three periods analyzed, the poor reported worse health status, while the wealthy reported more chronic diseases; health care utilization was pro-rich for medical and dental services. Yet, income-related inequality in health care utilization has been declining. Private health insurance, education, and income are the major contributors to the inequalities identified. Income-related inequality in the use of medical and dental health care is gradually declining in Brazil. The decline is associated with implementation of pro-equity policies and programs, such as the Community Health Agents Program and the Family Health Program.

Capacidade funcional em pacientes com diabetes mellitus no município de Matinhos, Paraná

O diabetes mellitus (DM) é decorrente de um inadequado funcionamento metabólico crônico, caracterizado por hiperglicemia com distúrbio dos carboidratos, gordura e metabolismo da proteína. O DM tem impacto substancial no perfil físico-funcional dos pacientes, entre os quais se destaca o teste de caminhada de seis minutos (TC6'). O objetivo do estudo foi analisar a capacidade funcional, por meio da distância percorrida no TC6', dos pacientes com DM tipo 1 (DM1) e 2 (DM2) cadastrados em Estratégias de Saúde da Família (ESFs) e Programas de Agentes Comunitários de Saúde (PACS) do município de Matinhos, Paraná. De 800 pacientes cadastrados nas ESF e PACS, foram contatados 497, e 153 participaram do estudo, sendo 1,30% com DM1 e 98,69% com DM2. Os avaliados tiveram média de 60,49±11,24 anos, a glicemia foi 173,18 mg/dL e as médias de massa corporal, estatura e índice de massa corpórea foram respectivamente: 76,69±14,07 kg, 1,62±0,08 m e 29,11±4,61 kg/m². Não houve correlação entre nível glicêmico e idade (r=0,023), entre idade e TC6' (r=-0,056), e nível glicêmico e TC6' (r=0,11). Observou-se que 28,10% apresentavam doença cardiovascular, 60,13% eram hipertensos e 16,99% tabagistas. O tratamento medicamentoso prevaleceu sobre os tratamentos dieta e exercício. Houve diferença estatística (p<0,0001) entre a distância prevista e a percorrida no TC6', indicando que os pacientes com DM não atingiram os níveis esperados neste teste. Seria necessário realizar um programa multidisciplinar direcionado a essa população, com ações em atividade física e dieta, com o intuito de minimizar os efeitos do DM sobre os aspectos funcionais desses pacientes.

Federalismo e gastos em saúde: competição e cooperação nos municípios da região metropolitana de São Paulo

O objetivo do trabalho é examinar implicações da estrutura federativa brasileira na avaliação comparativa de desempenho dos gastos públicos no setor saúde. Busca discutir a responsabilização dos gestores públicos municipais e avaliar a eficiência técnica dos municípios da Região Metropolitana de São Paulo nas ações de atenção básica à saúde. A atenção básica é a única subfunção de competência exclusiva dos gestores locais; as demais ações em saúde são compartilhadas entre os próprios municípios e com os outros entes federativos, União e estados. Para explorar as características de cooperação e competição do federalismo, são analisados dados levantados relativos aos municípios e agregados para as diferentes regiões de saúde que compõem a Região Metropolitana. O foco do estudo é a avaliação da eficiência técnica, capacidade de uma entidade obter máximos outputs com menor quantidade de insumos, realizada com o uso da metodologia Data Envelopment Analysis (DEA). Os resultados indicam grande dispersão dos dados dos municípios tanto em termos de despesa quanto da quantidade de procedimentos realizados, incluindo a cobertura dos principais programas de atenção básica, o Programa de Saúde da Família e o Programa de Agentes Comunitários de Saúde; e apontam menos de 20% dos municípios como eficientes. A análise dos municípios dentro de suas respectivas regiões sugere a prevalência de práticas de competição sobre as de cooperação. Tais informações podem contribuir para melhorar a integração dos serviços de saúde em redes de atenção e para repensar os pactos estabelecidos entre os municípios de uma determinada região de saúde. Além disso, este artigo, ao apontar potencialidades e limites de metodologias/técnicas para geração de informações úteis à tomada de decisão, pode contribuir para o debate atual em torno da controladoria no setor público.

Múltiplos olhares sobre a mortalidade infantil no Ceará, Brasil

This qualitative study analyzes the perceptions of various social actors towards infant mortality and the program to reduce it in Ceará State, Northeast Brazil. The study compares two municipalities (counties) that showed opposite infant mortality trends from 1993 to 1997, during which time Ceará achieved international visibility for having reduced infant mortality statewide. A total of 48 semi-structured interviews with four groups of key informants health system managers, community health agents, mothers who had lost a child, and neighbor women with children in the same age bracket and content analysis revealed "multiple conflicting voices" on the issue. Although the level of political determination to implement the interventions varied between the two municipalities, the differences in perceptions concerning infant death were more striking between the various groups of social actors, regardless of the municipality. The study revealed a kind of authoritarian educational practice that jeopardizes acceptance of the Community Health Agents Program. Public policies are needed that give voice to the people closest to the experience of infant death.

AÇÕES DE EDUCAÇÃO PERMANENTE DESENVOLVIDAS PARA OS AGENTES COMUNITARIOS DE SAÚDE

Nesta pesquisa, delineada como qualitativa, descritiva e exploratória, objetivou-se conhecer as ações de educação permanente em saúde que vêm sendo desenvolvidas para os Agentes Comunitários de Saúde (ACS) e, especificamente, como estas podem influenciar o seu processo de trabalho. A amostra de 26 sujeitos de duas equipes da Estratégia Saúde da Família e do Programa de Agentes Comunitários de Saúde do Município de Palmeira das Missões - Rio Grande do Sul ocorreu pelo método intencional. A análise dos dados, coletados por meio de questionário, permitiu a construção de duas unidades temáticas: ações de educação permanente; intersecção entre educação permanente em saúde e processo de trabalho. Conclui-se que as ações de educação permanente são ofertadas de duas formas, ambas assistemáticas, não contínuas e de base tecnicista. Em referência ao processo de trabalho, os ACS entenderam a educação permanente em saúde, como muito importante na resolução de problemas e na atenção aos usuários.

Acessibilidade geográfica à atenção primária à saúde em distrito sanitário do município de Salvador, Bahia

OBJETIVOS: avaliar a acessibilidade geográfica à atenção primária à saúde da população coberta pelos Programa de Agentes Comunitários de Saúde (PACS) e Programa de Saúde da Família (PSF) de um distrito sanitário de Salvador. MÉTODOS: estudo avaliativo transversal. Os dados foram coletados a partir de entrevistas realizadas junto aos profissionais das onze equipes de PACS e PSF. A análise dos dados contemplou duas dimensões: acesso da população e lógica de territorialização. RESULTADOS: o distrito apresentava relevo bastante acidentado e todas as equipes informaram a existência de barreiras geográficas na área, em especial escadarias, morros e ladeiras. Não foi observada diferença significativa na acessibilidade às equipes de PACS e PSF. O processo de territorialização esteve dissociado da concepção de território-processo. Algumas áreas de abrangência das equipes situavam-se em locais afastados das UBS, constituindo-se em importante barreira ao acesso da população. CONCLUSÕES: o processo de implantação da estratégia PACS/PSF no distrito e o modelo de territorialização adotado não atenderam aos princípios que devem nortear a organização da atenção primária à saúde, resultando em restrições na acessibilidade geográfica da população coberta. Recomenda-se que seja realizada uma revisão do desenho atual da territorialização, visando uma melhor adequação às diretrizes do PSF e à promoção de uma maior acessibilidade à atenção primária.

Busca ativa de sintomáticos respiratórios no controle da tuberculose na percepção do Agente Comunitário de Saúde

The active search of patients with respiratory symptoms is one of the priorities of the National Tuberculosis Control Program. It is expected that this activity must be inserted in the daily work of the Community Health Agents (CHA), in order to find cases precociously. The objective was to analyze the incorporation of case finding (CF) in tuberculosis control in the CHA perception. Data were collected by a survey of laboratory sputum smear results before and after the implantation of CF in the Community Health Agent Program (CHAP) and by an the application of a questionnaire among CHA. After the implantation of CF, the number of sputum smear requests increased in the first two months but decreased in subsequent months. The aspects that may be complicating the sustainability of CF are operational, related to the CHAP's external work (75% CHA experienced difficulties to collect the sputum) and to health service organization (lack of integration between different care points in the health service system: discontinuity in information and communication flows among CHAP and Health Units, strictness in routines/time for sending the sputum to the laboratory). Concluding the family approach is a complex activity demanding that the CHA have a permanent supervision of the nurse or doctor.

Primary Care and Avoidable Hospitalizations

This article provides evidence of the effectiveness of family-based, community-oriented primary healthcare programs on the reduction of ambulatory care sensitive hospitalizations in Brazil. Between 1998 and 2002, expansions of the Family Health Program were associated with reductions in hospitalizations for diabetes mellitus and respiratory problems and Community Health Agents Program expansions were associated with reductions in circulatory conditions hospitalizations. Results were significant for only the female population only, suggesting that these programs were more effective in reaching women than men. Program coverage may have contributed to an estimated 126 000 fewer hospitalizations between 1999 and 2002, corresponding to potential savings of 63 million US dollars.

Sistema de Informações sobre Mortalidade: estudo de caso em municípios com precariedade dos dados

The study was part of a survey conducted in clusters of Brazilian municipalities (counties) characterized by serious underreporting of deaths, with the objective of estimating infant mortality in these areas in 2000. The article discusses the principal sources of information on infant deaths in these municipalities, as well as some problems related to the implementation of the Mortality Data System (SIM). The methodology included an active search for deaths in previously registered official and unofficial sources, which identified 344 deaths not processed in the SIM (66% of total deaths). There were a low percentage of deaths processed in the SIM and coming from official sources (notary public offices and healthcare facilities), thus highlighting problems with reporting of deaths, issuing of death certificates, and data flows. The important contribution by the Community Health Agents Program/ Family Health Program points to the need for active data search in this source as a routine activity in municipalities with underreporting of data. Insufficient training of professionals and high staff turnover were major issues in the system's deficient implementation.

Effectiveness of community health agents' actions in situations of social vulnerability

Evaluation is purposeful activity examining multiple, diverse realities [1] that affect the implementation of social interventions and their management [2]. As political activity, evaluation involves partnerships among managers, stakeholders and internal and external evaluators. These partners review common interests and concerns to modify policies and modi operandi, and ultimately, to influence human life [3]. Evaluation is particularly sensitive to social problems and expectations; it documents their features, incidence and prevalence [2]. This article reports the quanti-qualitative results of an in-service effectiveness evaluation of interventions to reduce health risks for socially vulnerable people by community health agents (CHAs) (Agentes Comunitarios de Saude) in Brazil. CHAs are key personnel within the nationwide community health agent program (CHAP), created in 1991, that operates within Brazil’s Family Health Strategy (FHS). CHAP considers social inclusion through health education and promotion, a cornerstone of collective health. Most CHAs are from the communities they serve. This article documents some crucial features of CHAs’ work in dangerous neighborhoods previously inaccessible to health professionals (HPs). Knowledge about these residents’ health needs, challenges and difficulties due to their social vulnerability may not have reached health care providers.

Concepts involved in the training and work processes of community healthcare agents: a bibliographical review

This paper is the outcome of a bibliographical review that aims at systemizing references in the literature to concepts involved in the training and work processes of community health agents under the Community Health Agent Program (PACS) and the Family Health Program. Published in scientific journals, manuals and official documents through to October 2004, 504 articles were consulted, of which 49 were selected and examined in full. The findings were systematically arranged under four themes, reviewing controversial aspects raised by authors, outstanding among which are: the 'discourse of change' statements in official documents, defining the Family Health Program as a reorientation strategy for the Primary Healthcare Model; the scope and ambiguity of understandings of the role of mediator and definitions of the duties and responsibilities of Community Healthcare Agents, as well as the gaps in their training.

Reforma psiquiátrica no Rio Grande do Sul: uma análise histórica, econômica e do impacto da legislação de 1992

Os autores apresentam uma análise da reforma psiquiátrica do Rio Grande do Sul, utilizando uma perspectiva histórica e uma abordagem por três vertentes: a psiquiatria institucional; os desenvolvimentos na área extra-hospitalar; e as políticas de saúde implementadas ao longo dos anos. A partir do referencial adotado, foi revisada a experiência brasileira e a do Rio Grande do Sul em particular, tendo como fontes: os bancos de dados MEDLINE e Lilacs e documentos oficiais do Ministério da Saúde e da Secretaria Estadual de Saúde do Rio Grande do Sul. Hoje, após 14 anos da promulgação da Lei Estadual nº 9716, que dispõe sobre a reforma psiquiátrica no Rio Grande do Sul e determina a substituição progressiva dos hospitais psiquiátricos por uma rede de atenção integral em saúde mental, nota-se que o número de leitos psiquiátricos foi reduzido em 35%, e a proposta de implantação da rede "alternativa" de assistência ao doente mental não foi implementada da forma preconizada, tampouco de maneira igualitária. Tendo em vista que os atuais desafios, tais como o fenômeno da "porta giratória" e o paciente crônico, refletem a necessidade de extensão dos cuidados primários e secundários, a experiência do Rio Grande do Sul permite pôr em discussão a possibilidade de modificação da estratégia, de tal modo que, ao invés de tentar estruturar um "sistema dentro do sistema", como hoje está colocado, possa-se tirar melhor proveito da integração da saúde mental aos programas-eixo do SUS, como o Programa de Saúde da Família e o Programa de Agentes Comunitários de Saúde.

Community health agent program: perception by patients and health service workers

Two basic premises of Brazil's Community Health Agents Program (PACS) are to value the family and community to which the program belongs and to encourage their participation in health promotion and disease prevention. This study focused on the work developed by PACS in Bauru, São Paulo State, as perceived by the community health agents and the families served by them. As the study's point of departure, 22 community health agents and 22 representatives of families were interviewed, randomly selected according to residential micro-areas. Two focus groups were formed according to the PACS to which the community agents and families belonged. Qualitative analysis of the answers demonstrated agreement between the perceptions by community health agents and the community in the two focus groups. However, the two focus groups differed from each other. Distinct realities were observed in the two communities, thereby orienting new program actions and handling of local difficulties.