Maria Helena Magalhães de Mendonça

Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil

The article analyzes the implementation of the Family Health Strategy (FH) and discusses its potential to guide the organization of the Unified Health System in Brazil, based on the integration of FH to the health care network and intersectorial action, crucial aspects of a comprehensive primary health care. Four case studies were carried out in cities with high FH coverage (Aracaju, Belo Horizonte, Florianopolis e Vitoria), using as sources: semi-structured interviews with managers and surveys with health care professionals and registered families. The integration analysis highlighted the position of FH Strategy in the health services network, the integration mechanisms and the availability of information for continuity of care. Intersectoriality was researched in relation to the fields of action, scope, sectors involved, presence of forums, and team initiatives. The results point to advances in the integration of FH to the health care network, strengthening basic services as services that are regularly sought and used as a preferential first contact services, although there are still problems in the access to specialized care. The intersectorial initiatives were broader when defined as integrated municipal government policy for the construction of interfaces and cooperation between the diverse sectors.

Indicadores de atenção básica em quatro municípios do Estado do Rio de Janeiro, 2005: resultados de inquérito domiciliar de base populacional

O inquerito domiciliar de base populacional, realizado em quatro dos 22 municipios com mais de cem mil habitantes do Estado do Rio de Janeiro que implementaram o Projeto de Expansao e Consolidacao do Saude da Familia (Proesf), visa a institucionalizacao da avaliacao e monitoramento da atencao basica. Este estudo desenvolveu-se no contexto dos Estudos de Linha de Base (ELB) do Proesf. O instrumento utilizado e uma adaptacao do questionario aplicado anteriormente em âmbito nacional para avaliacao de desempenho de saude, sob a otica dos usuarios. As alteracoes voltaram-se para a avaliacao da atencao basica, com foco no Programa de Saude da Familia (PSF). Construiram-se indicadores de cobertura, qualidade de atendimento pre-natal, assistencia ao parto, saude infantil, prevencao de câncer de colo uterino e mama, assistencia a idosos e saude bucal. Destacaram-se os resultados observados na prevencao de câncer de colo de utero, pelas elevadas coberturas de exame ginecologico no periodo de tres anos, ficando evidente a fragilidade do sistema de saude em relacao ao tempo de entrega do resultado do exame. Reforca-se a importância de avaliar a qualidade da atencao basica recebida sob a otica do usuario, para o estabelecimento de metas e definicao de prioridades.

Desafios para gestão do trabalho a partir de experiências exitosas de expansão da Estratégia de Saúde da Família

This article discusses the management of the work in Family Health Strategy in four major urban centers. The research includes perspectives from different actors who compose and integrate the network of working relationships in Public Health System through questionnaires with employees of professional categories family health team and interviews with managers and representatives of professional bodies. It is a qualitative-quantitative evaluation study. The dimensions analysed were: insertion and remuneration policies, strategies and qualification of employees. The insertion and remuneration policy highlights the replacement of outsourced frames and hiring by public tender that allows links labor more stable. Other strategies are the establishment of allowance for expertise in areas of greater social vulnerability and the assimilation of specialists in Family and Community Medicine with other experts engaged in secondary services. The political will of municipal Manager to qualify the workforce of family health, maintaining the provision of adequate human resources needs of the health system is a fundamental factor for the consolidation of family health strategy in the face of the low degree of specialization of professionals to work in primary health care.

Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal

This article presents the results of a study on Federal health policy in the Brazilian Legal Amazon (BLA) from 2003 to 2005, aimed at backing the development of regional health policies. The region has peculiar dynamics, an extensive border area, and adverse social indicators. The methodology included documental and financial analysis, participatory observation, interviews with heads of various Federal Ministries and State and Municipal health secretaries from the BLA; characterization of geographic situations in the BLA; and field studies in 15 municipalities. Institutional consolidation of health policy proved to be low in the Amazon during the study period, due to structural, institutional, and political difficulties. The identification of six geographic situations was useful for systematizing land use differences with repercussions on health, and which should be considered when implementing public policies. There is a certain gap between Federal actions and territorial dynamics, expressed as a mismatch between the current policy and its recognition by local administrators. In addition to establishing a regional policy for the Amazon, there is an evident need for differentiated policies within the region.

A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB

O artigo analisa a posicao da Estrategia Saude da Familia na rede de atencao a saude sob a perspectiva das 16.566 equipes de Saude da Familia e dos 62.505 usuarios participantes do Programa Nacional para Melhoria do Acesso e da Qualidade da Atencao Basica em 2012. Os resultados indicam que as equipes atuam cada vez mais como porta de entrada preferencial, atendendo a demandas diversas e exercendo a funcao de filtro para a atencao especializada. Contudo, persistem importantes barreiras organizacionais para acesso, os fluxos estao pouco ordenados, a integracao da APS a rede ainda e incipiente e inexiste coordenacao entre APS e atencao especializada.

The association between low-socioeconomic status mother’s Sense of Coherence and their child’s utilization of dental care

OBJECTIVES The objective of this study was to investigate the relationship of low-socioeconomic status mothers Sense of Coherence (SOC) and their childs utilization of dental care services in a city of Southeast Brazil. METHODS A cross-sectional study was conducted on a sample of 190 schoolchildren aged 11-12 and their mothers in Sao João de Meriti-RJ, Southeast Brazil. The outcome variables were childrens use of dental care services and visiting dentists mainly for check-ups. Demographic and socioeconomic characteristics and data regarding childrens dental care use were collected through interviews with mothers. Childrens oral health-related behaviours as well as dental status (DMFS index), dental pain, Visible Dental Plaque and Bleeding on Probing Index were registered. Mothers SOC was assessed through the validated short version (13-item) of Antonovskys scale. Multiple logistic regression was used in the data analysis. RESULTS Of the mothers, 81.1% reported on their childs utilization of dental care services. Of them, 42.9% considered check-ups as the main reason for taking their children to dental services. Children whose mothers had higher levels of SOC were more likely to utilize dental care services (OR=2.08 95%CI=1.17-3.64) and visit a dentist mainly for check-ups (except for dental treatment) (OR=2.02 95%CI=1.06-3.81) than those whose mothers had lower levels of SOC. These findings were adjusted for socioeconomic status, childrens oral health-related behaviours and oral health measures. CONCLUSIONS Mothers SOC was a psychosocial factor associated with their childs pattern of use of dental care services in low-socioeconomic status families.

A salutogenic approach to oral health promotion

Theoretical frameworks on health promotion focusing on social determinants of oral health have highlighted promising approaches for improving the oral health of populations and reducing inequities in oral health. In the last two decades the salutogenic theory has gained ground in the field of health promotion, but not in oral health promotion. Instead of focusing on risk factors and behavior change, the theory highlights the importance of resources and the ability to use them. The models central construct, sense of coherence (SOC), suggests explanations of the relationship between life stressors and health status. The stronger the SOC, the more successfully people will cope with stressors and thus maintain their health. This paper discusses the potential of the salutogenic theory to guide the development of actions in the five fields of oral health promotion: creating supportive environments; promoting health through public policy; strengthening community action; developing personal skills; and reorienting health services. The theory can serve as a framework for oral health promotion measures that strengthen the available resources, create better ones, and enable people to identify and benefit from them.

O desafio da política de atendimento à infância e à adolescência na construção de políticas públicas eqüitativas

The author analyzes the new social policy shaped by the assimilation of the notion of integral social protection with a view towards equity. The premises marked the social reform contained in the wording of the 1988 Constitution and in the laws regulating the respective rights during the 1990s, including public social assistance, health care, and education. The article demonstrates how, in the former context, Brazils children and adolescents were subject to great vulnerability due to their position in the countrys social structure, aggravated by differential access to public goods and services. An analysis of the health care policy for children and adolescents, emphasizing an inter-sectoral approach and redefining social and health programs and measures in the 1990s, was not intended to be conclusive but did point to some trends in the reorganization of public social assistance policy for low-income youth, in keeping with gains obtained in social indicators of vulnerability in the areas of health, education, and labor during the last decade. Still, the author concludes that this policy reorientation renewed the tension between targeting more vulnerable segments of the population with selective measures as compared to universal and comprehensive access to social protection.

Práticas assistenciais das Equipes de Saúde da Família em quatro grandes centros urbanos

This paper examines reports on how care is administered by Family Health Teams (FHT) doctors and nurses in four state capitals. It identifies issues relating to priority actions, routine activities and the association between the professional profile and how selected activities are performed, in an attempt to ascertain how far these approximate to the comprehensive approach to primary health care. The cross-section reflects results from data collected via self-applied questionnaires. Cross-analyses were made using the Pearson chi-square (÷2) test for categorical variables. A and B variables are, or are not, associated, at a 5% level of significance. The analyses point to a tendency to strike a balance in meeting programmed and spontaneous demand, corroborating the person-centered approach. Action to address chronic infectious disorders is not a priority for all FHTs, which impairs health surveillance actions and comprehensive care. Home visits are not yet a weekly activity for all personnel. Lack of involvement in community activities restricts care to conventional practices and undermines the logic of change of model. Contradictions identified between training and practice indicate a need to review policies for ongoing professional development.

Health practices in the reorientation of primary care in Rio de Janeiro State, Brazil, from the perspective of users and health professionals

This evaluative study focused on expansion of the Family Health Strategy in large cities in Rio de Janeiro State, Brazil. The study analyzed the functionality of health care modalities, performance, and supply of comprehensive care itself and its link to services at other levels. The thrust of the analysis was comprehensiveness of care in the daily routine of health services, with a focus on childbearing-age women, and with pregnancy as the tracer condition. The results emerged from an analysis of focus groups with health care users and health professionals, based on: characterization of key actors; their perceptions concerning health, healthcare model, and organization of primary care services and practices. The groups suggested that the actors perceive health as identified with social determinants. Access to services and actions was differentiated in the family health unit by enrollment of the clientele and active search, and the study showed the lack of a structured network. The study indicates that work processes contemplating the social determination of health and its intersectorality can lead to expanded access to comprehensive care for childbearing-age women.