Zulmira Maria de Araújo Hartz

Qualidade de vida e saúde: um debate necessário

This paper discusses the relationships between quality of life and health by applying the discourses emerging in the health sector to other fields and other disciplines. These relationships constitute social representation based on subjective parameters (well-being, happiness, love, pleasure, personal satisfaction), and on objective ones such as satisfaction of basic needs and of the needs created by the degree of economical and social development of a given society. The text presents the main instruments which have been constructed during the last years for measuring quality of life, as well as the debate they cause. It also debates the semantic field where the representations and actions in favour of quality of life - such as the concept of development, democracy, quality, way and conditions of life - develop. In relation to the field of health, this article discusses the tendency to restrict the concept of quality of life to the biomedical area, associated with an economic assessment. It shows the variety of instruments created for measuring quality of life in accordance with the concept. Health promotion is considered one of the most relevant strategies in this field in order to avoid medical reductionism and to develop an interdisciplinary dialogue. It is argued that this proposal, however, still needs to be refined and tested in sanitary practices.

Qualidade da atenção ao parto em maternidades do Rio de Janeiro

OBJETIVO: Avaliar a qualidade da atencao durante o processo de trabalho de parto de acordo com normas da Organizacao Mundial de Saude. METODOS: Trata-se de estudo do tipo caso-controle, realizado em duas maternidades: publica e conveniada com o Sistema Unico de Saude, no Municipio do Rio de Janeiro. A amostra foi composta por 461 mulheres na maternidade publica (230 partos vaginais e 231 cesareas) e por 448 mulheres na maternidade conveniada (224 partos vaginais e 224 cesareas). De outubro de 1998 a marco de 1999, foram realizadas entrevistas com puerperas e revisao de prontuarios. Foi construido escore sumarizador da qualidade do atendimento. RESULTADOS: Observou-se baixa frequencia de algumas praticas que devem ser encorajadas, como presenca de acompanhante (1% na maternidade conveniada, em ambos os tipos de parto), deambulacao durante o trabalho de parto (9,6% das cesareas na maternidade publica e 9,9% dos partos vaginais na conveniada) e aleitamento na sala de parto (6,9% das cesareas na maternidade publica e 8,0% das cesareas na conveniada). Praticas comprovadamente danosas e que devem ser eliminadas como uso de enema (38,4%), tricotomia, hidratacao venosa de rotina (88,8%), uso rotineiro de ocitocina (64,4%), restricao ao leito durante o trabalho de parto (90,1%) e posicao de litotomia (98,7%) para parto vaginal apresentaram alta frequencia. Os melhores resultados do escore sumarizador foram obtidos na maternidade publica. CONCLUSOES: As duas maternidades apresentam frequencia elevada de intervencoes durante a assistencia ao parto. A maternidade publica, apesar de atender clientela com maior risco gestacional, apresenta perfil menos intervencionista que maternidade conveniada. Procedimentos realizados de maneira rotineira merecem ser discutidos a luz de evidencias de seus beneficios.

Avaliação da adequação da assistência pré-natal na rede SUS do Município do Rio de Janeiro, Brasil

A persistencia de desfechos perinatais negativos no Municipio do Rio de Janeiro, Brasil, sugere problemas na qualidade da assistencia pre-natal. A ultima investigacao realizada nessa cidade mostrou adequacao de apenas 38% dessa assistencia. O objetivo deste estudo e avaliar a adequacao da assistencia pre-natal na rede do SUS do Municipio do Rio de Janeiro. Foi realizado um estudo transversal, em 2007-2008, por meio de entrevistas com 2.422 gestantes em atendimento nos servicos de pre-natal de baixo risco. Para avaliacao da adequacao da assistencia, foi utilizado o indice PHPN, com as recomendacoes do Programa de Humanizacao do Pre-natal e Nascimento, do Ministerio da Saude, e um indice PHPN ampliado, em que foram acrescentados procedimentos clinico-obstetricos, prescricao de sulfato ferroso suplementar e acoes educativas. Foi encontrada adequacao de 38,5% para o PHPN e 33,3% para o PHPN ampliado. Estrategias de ampliacao da captacao precoce das gestantes e melhor utilizacao dos contatos com os servicos para a realizacao de acoes de atencao a saude sao prioritarias para a reversao desse quadro.The persistence of negative perinatal outcomes in Rio de Janeiro suggests problems in the quality of prenatal care. The most recent study in the city showed that only 38% of prenatal care was adequate. This study aimed to evaluate the adequacy of prenatal care under the Brazilian Unified National Health System in the city of Rio de Janeiro. A cross-sectional study in 2007-2008 interviewed 2,422 women receiving prenatal care for low-risk pregnancy. Evaluation of care used the PHPN index, based on guidelines from the Program for Humanization of Prenatal Care and Childbirth (Brazilian Ministry of Health) and an expanded PHPN index, which included clinical-obstetric procedures, prescription of supplementary ferrous sulfate, and educational activities. According to the PHPN index, 38.5% of prenatal care was adequate, as compared to 33.3% based on the expanded PHPN index. Strategies to expand early entry of pregnant women into prenatal care and better use of their contact with the health services in order to promote healthcare measures are essential to correct this situation.

Avaliação dos programas de saúde: perspectivas teórico metodológicas e políticas institucionais

Este artigo apresenta as perspectivas teorico-metodologicas da avaliacao em saude considerando o contexto politico-decisorio de uma possivel estruturacao governamental por programas e uma gestao por resultados no proximo quinquenio. As principais questoes discutidas se organizam em tres eixos: 1) a necessidade de um modelo teorico orientando o processo de avaliacao; 2) a exigencia de pluralidade metodologica dada a contextualizacao das acoes programaticas a complexidade das medidas de resultados; e 3) a obrigatoriedade de dispositivos institucionais que regulamentem os estudos de avaliacao garantindo a qualidade e utilidade do produto final. Ao final do texto se focaliza a importância de se fomentar uma pesquisa avaliativa voltada para a construcao de evidencias cientificas em saude publica e suas implicacoes para a formacao de avaliadores.

Atenção à saúde da criança: uma análise do grau de implantação e da satisfação de profissionais e usuários em dois municípios do estado de Pernambuco, Brasil

OBJECTIVES: to evaluate the implementation of child health care at two municipalities of the state of Pernambuco, Brazil. METHODS: evaluative research, implementation analysis. It was considered as units of analysis: unit of the Family Health Program (FHP) with professionals trainned in the Integrated Management of Childhood Illness Strategy (IMCI), unit without this training and conventional health care unit. The degree of implementation was achieved by case management and structure evaluation. Professional and users perceptions were appraised by interview and focus group discussion. RESULTS: degree of implementation satisfactory for FHP services, insatisfactory at the conventional unit in Municipality 1 and insatisfactory for units in Municipality 2. Professionals considered effectiveness of services and interpersonal relationship as good, but difficulties in the reference system and lack of integration with work group of conventional units. Users reported, good services effectiveness, but access and interpersonal relationship difficulties. CONCLUSIONS: deficiencies in case management and potentiality of the health care provided by nurse professional were determinant aspects for the variability on implementation degree. It was not possible to define the influence of the IMCI strategy. There is better professional and user satisfaction at FHP units, but problems of access and integrality of health care.

Programas de promoção da saúde do idoso: uma revisão da literatura científica no período de 1990 a 2002

O artigo mostra as experiencias de avaliacao em promocao da saude do idoso a partir da revisao de programas na area. Fez-se busca bibliografica em bases de dados, sites e periodicos especializados, no periodo 1990-2002. O criterio de inclusao foi ser programa com foco multitematico com atividades educativas e/ou preventivas. Os estudos revisados revelam um campo multifacetado quanto as tendencias teorico-metodologicas e as estrategias de pesquisa. Na experiencia internacional predomina o estudo quase-experimental, enquanto no Brasil sao comuns os relatos de experiencias. As principais dimensoes avaliadas nos estudos sao a receptividade dos idosos, a melhoria de indicadores psicossociais, a aderencia a recomendacoes comportamentais e o processo educativo. Nos resultados destacam-se a boa receptividade dos idosos e certa discrepância de efeitos na afericao quantitativa de indicadores. Os estudos qualitativos apontam caminhos para apreensao dos processos. Conclui-se que a avaliacao em promocao da saude do idoso e pouco desenvolvida no Brasil e a pesquisa de sintese dos programas pode ser parâmetro para o desenvolvimento das experiencias em nosso contexto.

The role of the Family Health Program in the organization of primary care in municipal health systems

The contribution of primary care to population health and health systems organization has been well documented, but some authors have highlighted that in Third World countries it has gained more ground in discourse than in facts and practices, with different possible configurations. The objectives of the current study were to evaluate and correlate organizational and local contextual characteristics to the degree of implementation of primary care in two municipalities (counties) in the State of Bahia State, Brazil, that had adopted the Family Health Program (FHP) as the systems central thrust. The research was based on two case studies with interwoven levels of analysis, using as the point of departure the underlying goal-image of primary care in the definition of criteria and standards for degree of implementation. The total scores for Municipalities A and B were 66 and 81, respectively (maximum total score = 100), while differences were observed between the urban and rural teams. The political and institutional contexts helped explain differences in the degree of implementation of primary care, but regardless of the municipal context, the study showed the emergence of organizational innovations closely related to the FHP.

Sífilis congênita: evento sentinela da qualidade da assistência pré-natal

OBJETIVO: Analisar a assistencia pre-natal na prevencao da transmissao vertical da sifilis. METODOS: Estudo transversal representativo para as gestantes de baixo risco atendidas em unidades de saude do municipio do Rio de Janeiro, RJ, periodo de 2007 a 2008. A identificacao de gestantes com diagnostico de sifilis na gestacao foi feita por meio de entrevistas, verificacao do cartao de pre-natal e busca de casos notificados em sistemas publicos de informacao em saude. Os casos de sifilis congenita foram identificados por meio de busca nos sistemas de informacao em saude: Sistema de Informacao de Agravos de Notificacao (Sinan), Sistema de Informacao sobre Mortalidade (SIM) e Sistema de Informacoes Hospitalares (SIH) do SUS. RESULTADOS: Foram identificados 46 casos de sifilis na gestacao e 16 casos de sifilis congenita com uma prevalencia estimada de 1,9% (IC95% 1,3;2,6) de sifilis na gestacao e de 6/1.000 (IC95% 3;12/1.000) de sifilis congenita. A taxa de transmissao vertical foi de 34,8% e tres casos foram fatais, um abortamento, um obito fetal e um obito neonatal, com proporcoes elevadas de baixo peso e prematuridade. A trajetoria assistencial das gestantes mostrou falhas na assistencia, como inicio tardio do pre-natal, ausencia de diagnostico na gravidez e ausencia de tratamento dos parceiros. CONCLUSOES: Estrategias inovadoras, que incorporem melhorias na rede de apoio diagnostico, sao necessarias para enfrentamento da sifilis na gestacao, no manejo clinico da doenca na gestante e seus parceiros e na investigacao dos casos como evento sentinela da qualidade da assistencia pre-natal.OBJECTIVE To evaluate antenatal care in reducing the vertical transmission of syphilis. METHODS A cross-sectional study was designed to be representative of low-risk pregnancies in women cared for at the Brazilian Unified Health System (SUS) network in the city of Rio de Janeiro, from November 2007 to July 2008. Pregnant women diagnosed with syphilis were identified through interviews, checking their antenatal care card and searching for reported cases in the public health information systems. Cases of congenital syphilis were sought at the disease reporting system (Sinan), the Mortality Information System (SIM) and the SUSs Hospital Information System (SIH). RESULTS Syphilis was identified in 46 of the pregnancies, and 16 cases of congenital syphilis were identified, resulting in a prevalence of 1.9% (95%CI 1.3;2.6) of syphilis in pregnancy and an incidence of 6/1,000 (95%CI 3;12/1,000) of congenital syphilis. The vertical transmission rate was 34.8% with three cases resulting in death (1 abortion, 1 stillborn and 1 neonatal death) and high proportions of prematurity and low birth weight. The healthcare pathway of those women revealed flaws in the care they received, such as late entry to antenatal care, syphilis remaining undiagnosed during pregnancy and lack of treatment for the partner. CONCLUSIONS Innovative strategies are needed to improve the outcomes of syphilis in pregnancy, including improving the laboratory network, the quality of care delivered to the pregnant women and their sexual partners and, most important of all, investigating every case of congenital syphilis as a sentinel event in the quality of antenatal care.

Validation of a tool for assessing the quality of pharmaceutical services

This paper presents the validation process for a tool assessing basic pharmaceutical services through an analysis of the implementation of a Basic Pharmaceuticals Distribution Program by the Brazilian Federal government. The process began with the drafting of a theoretical model, based on a state-of-the-art review and allowing the selection of various conceptual dimensions and respective criteria that best represented the construct. The second step involved weighting indicators for the construction of quality scores. Three models were tested for ranking implementation levels, and seven simulations were conducted, determining the score most closely reflecting the selected indicators in two different matrices. The objective was to select the most coherent and consistent version between implementation levels and expected outcomes, while simultaneously enhancing validity of chosen criteria. Testing of the various models and the results obtained showed that augmenting the validity of the study was possible without altering data. This endeavor is justified in understanding the scope and limitations of these measurements and of the choices involved in issues concerning their weighting and interpretation.

Óbito por dengue como evento sentinela para avaliação da qualidade da assistência: estudo de caso em dois municípios da Região Nordeste, Brasil, 2008

Despite the existing resources for adequate dengue patient care in the Brazilian healthcare system, the case-fatality rate for the disease is still high in the country. In order to identify factors associated with dengue-related death, this study evaluated quality of care according to the degree of implementation of specific measures, the technical and scientific quality of care, and access to health services in two municipalities (counties) in Northeast Brazil. An evaluative study of the implementation analysis type was performed, with death from dengue as the sentinel event for quality of care. To assess the degree of implementation and quality of care, the study scored the interview criteria and patient chart analysis; access was evaluated by thematic analysis. As for structure and process, the health services were found to be partially adequate (70%). No geographic or economic barriers were found to explain the occurrence of deaths. Technical and scientific quality failed to achieve adequate levels in the municipalities (46% and 30%) or in the specific services, and clinical management of dengue by the health services proved insufficient.