Incorporation, adaptation and rejection of obstetric practices during the implementation of the "Adequate Childbirth Program" in Brazilian private hospitals: a qualitative study.

BACKGROUND: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. METHOD: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. RESULTS: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. CONCLUSIONS: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful.

Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice.

Process of adhesion of the Adequate Childbirth Program to improve obstetric care in private hospitals in Brazil.

BACKGROUND: In 2015, a quality improvement project called "Projeto Parto Adequado-PPA" was implemented in Brazilian private hospitals to reduce unnecessary high rates of cesarean sections. This study aimed to analyze the decision-making process of managers and care leaders to adhere to the PPA. METHODS: The Healthy Birth study is evaluative research that used mixed methods to evaluate the implementation and effects of the Adequate Childbirth Program in 12 hospitals that participated in the program. Eight out of 12 hospitals were selected for a qualitative approach. We interviewed ten managers and 24 care leaders from July to October 2017. The interviews were transcripted, and data was systematized using the MaxQda software, with Thematic Content Analysis, to identify the facilitators and barriers for adherence to the Adequate Childbirth Program. We used the conceptions of the Diffusion of Innovation as an analytical reference. RESULTS: The main reasons to adhere to the Adequate Childbirth Program were the absence of other quality improvements programs in Brazilian private services using multifaceted interventions, social and market status for participating; commitment to quality of care; and the possibility of structural reforms related to the Adequate Childbirth Program implementation. In addition, inviting hospital influencers to learn about the objectives and intentions of the project before joining was considered an important strategy to motivate hospitals. CONCLUSION: Social, cultural, and economic constructs motivated adherence. The invitation strategy used by the Adequate Childbirth Program coordination, through socially respected members in Brazil, such as doctors, was highly valued by the leaders of the hospital team and encouraged adherence to the Program.

In 2015, a quality improvement program, called the "Adequate Childbirth Program" (PPA), was recommended by the National Supplementary Health Agency so that Brazilian private hospitals could, through a change in the care model, reduce unnecessary cesarean sections and stimulate the natural and safe process in childbirth. The process of adhering to the PPA was studied in this article. Ten managers and 24 assistant leaders were interviewed in 08 private hospitals in Brazil. The main reasons for joining the PPA were the absence of other quality improvement programs; for being a program considered necessary in the country's midwifery, which could increase the prestige of hospitals in the view of women and families; for proposing an improvement in the quality of care; and for stimulating of structural and ambiance reforms. Social, cultural, and economic values motivated hospital adherence. The invitation strategy used by the PPA coordination, through socially respected members in Brazil, such as medical professionals, was highly valued by the hospital's leaders and encouraged adherence to the Program.

Declining prevalence of hepatitis A virus antibodies among children from low socioeconomic groups reinforces the need for the implementation of hepatitis A vaccination in Brazil.

Age-related seroprevalence studies that have been conducted in Brazil have indicated a transition from a high to a medium endemicity of hepatitis A virus (HAV) infection in the population. However, most of these studies have focused on urban populations that experience lower incidence rates of HAV infection. In the current study, the prevalence of anti-HAV antibodies was investigated in children with a low socioeconomic status (SES) that live on the periphery of three capital cities in Brazil. A total of 1,162 dried blood spot samples were collected from individuals whose ages ranged from one-18 years and tested for anti-HAV antibodies. A large number of children under five years old (74.1-90%) were identified to be susceptible to HAV infection. The anti-HAV antibody prevalence reached ≥ 50% among those that were 10-14 years of age or older. The anti-HAV prevalence rates observed were characteristics of regions with intermediate level of hepatitis A endemicity. These data indicated that a large proportion of children with a low SES that live at the periphery of urban cities might be at risk of contracting an HAV infection. The hepatitis A vaccine that is currently offered in Brazil is only available for high-risk groups or at private clinics and is unaffordable for individuals with a lower SES. The results from this study suggest that the hepatitis A vaccine should be included in the Brazilian National Program for Immunisation.

Decision aid for prostate cancer screening in Brazil.

OBJECTIVE: To present the development and validation processes of a decision aid for prostate cancer screening in Brazil. METHODS: Study with qualitative-participatory design for the elaboration of a decision aid for prostate cancer screening, with the participation of a group of men and physicians inserted in primary health care in 11 Brazilian states. Evidence synthesis, field testing, and use in clinical scenarios were performed to adapt the content, format, language, and applicability towards the needs of the target audience in the years 2018 and 2019. The versions were subsequently evaluated by the participants and modified based on the data obtained. RESULTS: We elaborated an unprecedented tool in Brazil, with information about the tests used in the screening, comparison of their possible benefits and harms and a numerical infographic with the consequences of this practice. We verified the decision aid usability to assist in the communication between the doctor and the man in the context of primary health care, besides identifying the need for greater discussion about sharing decisions in clinical scenarios. CONCLUSION: The tool was easy to use, objective, and has little interference in consultation time. It is a technical-scientific material, produced by research, with the participation of its main target audience and which is available free of charge for use in Brazilian clinical scenarios.

Comparison between self-image and body mass index among children living in a slum in Rio de Janeiro, Brazil, 2012. / Comparação entre autoimagem e índice de massa corporal entre crianças residentes em favela do Rio de Janeiro, 2012.

OBJECTIVE: To analyze agreement/discrepancy between body self-image and Body Mass Index (BMI), according to variables related to type of food and environment influence. METHODS: This was a cross-sectional analysis of 195 prepubescent children (≥5 years), attending a Primary Health Care service in Manguinhos, Rio de Janeiro. Z-scores were applied to classify BMI. Self-image was collected using the figure rating scale (silhouettes) validated for children. A multinomial model was used to estimate covariate association with the underestimated/overestimated BMI outcome in relation to self-image. RESULTS: Overweight children underestimated their BMI, as compared with self-image, more often (58.6%) than obese children (22.0%) and children with adequate BMI (49.0%). This dissociation was correlated to participation in a cash transfer program (OR=2.01 - 95%CI 1.04;3.90) and daily consumption of sugar-sweetened foodstuffs (OR=3.88 - 95%CI 1.05;14.39). CONCLUSION: Underestimation of BMI among overweight children should be taken into account by Primary Health Care services, in order to enhance intervention practices.

The professional path of postgraduates of a professional master's degree in primary health care in the municipality of Rio de Janeiro, Brazil: an evaluative study. / Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo.

A four-block exploratory study was conducted with an electronic online, anonymous questionnaire to study the path of postgraduates  from two professional master's degree classes, as follows: personal, current professional activity, course-professional situation relationship, and open-ended questions for positive/negative points. Results: Most of them remained in the primary care area and public services; in health care and as tutors; developed a course-related work activity, and 75% reported a high impact of the course. A lower effect was perceived in the remuneration. A higher effect was noted in the professional training, the networks of relationships, personal growth, and work. The active pedagogical strategies were well evaluated. Conclusion: This is a feasible and applicable evaluation method for graduate monitoring systems, and it allows knowing the relationship between training and work.

Visando estudar a trajetória de egressos de duas turmas de Mestrado Profissional realizou-se estudo exploratório, com questionário eletrônico on line, anônimo, com quatro blocos: pessoal; atividade profissional atual; relação do curso-situação profissional e ainda perguntas abertas para pontos positivos/negativos. Resultados: a maioria mantinha-se na área da atenção primária e em serviços públicos; na assistência à saúde e muitos como preceptores; desenvolviam atividade no trabalho relacionada ao curso e 75% relatam alto o impacto do curso. Menor efeito foi percebido na remuneração e maiores na formação profissional, nas redes de relações; no crescimento pessoal e no trabalho. As estratégias pedagógicas ativas foram bem avaliadas. Conclusão: metodologia de avaliação factível e aplicável para sistemas de acompanhamento de egressos; permite conhecer a relação formação e trabalho.

Vivências e sentidos do uso prejudicial de álcool e outras drogas / Experiences and meanings of the harmful use of alcohol and other drugs / Experiencias y significados del consumo nocivo de alcohol y otras drogas

Objetivo: compreender os sentidos e as vivências de uso prejudicial de álcool e outras drogas, sob a ótica de usuários da Rede de Atenção Psicossocial. Método: estudo qualitativo, descritivo, exploratório, que entrevistou 13 participantes adultos nos meses de setembro a dezembro de 2019. A análise firmou-se nos aportes da análise de conteúdo temática de Bardin, resultando as categorias, perdas e fracasso na vida, culpa, dualismo vida e morte - das cinzas à fênix, recaída. Resultados: o uso de substâncias remete a perdas familiares, de moradia, trabalho, dignidade; a destruição, fracasso. A recaída denota falha, pecado; acarreta culpa, auto-estigma. O sofrimento trespassa as tentativas de buscar do cuidado; reverbera na perda do sentido da vida, no comportamento suicida ou na resiliência e esperança-equilibrista. Conclusão: a clínica ampliada deve valorizar a geografia afetiva dos usos e a redução de danos.

Objectives: to understand the meanings and experiences of harmful use of alcohol and other drugs, from the perspective of users of the Psychosocial Care Network. Method: qualitative, descriptive, exploratory study that interviewed 13 adult participants in the months from September to December 2019. The analysis was based on Bardin's thematic content analysis, resulting in the categories, loss and failure in life, guilt, life and death dualism - from ashes to phoenix, relapse. Results: substance use refers to loss of family, housing, work, dignity; destruction, failure. Relapse denotes failure, sin; it brings guilt, self-stigma. Suffering goes through the attempts to seek care; it reverberates in the loss of the meaning of life, suicidal behavior or resilience and hope-equilibrist. Conclusion: the expanded clinic must value the affective geography of uses and harm reduction.

Objetivos:comprender los significados y experiencias del uso nocivo de alcohol y otras drogas, desde la perspectiva de los usuarios de la Red de Atención Psicosocial. Método: estudio cualitativo, descriptivo, exploratorio, que entrevistó a 13 participantes adultos en los meses de septiembre a diciembre de 2019. El análisis se basó en el análisis de contenido temático de Bardin, resultando en las categorías, pérdida y fracaso en la vida, culpa, dualismo vida y muerte - de las cenizas al ave fénix, recaída. Resultados:el uso de sustancias se refiere a pérdidas familiares, vivienda, trabajo, dignidad; destrucción, fracaso. La recaída denota fracaso, pecado; conlleva culpa, autoestigma. El sufrimiento pasa por los intentos de buscar atención; reverbera en la pérdida del sentido de la vida, conducta suicida o resiliencia y esperanza-equilibrista. Conclusión: la clínica ampliada debe valorar la geografía afectiva de los usos y la reducción de daños.

Gestão participativa na Atenção Primária à Saúde: ensaio sobre experiência em território urbano vulnerável / Participative management in Primary Health Care: an essay on an experience in a vulnerable urban territory

RESUMO A gestão participativa, embora instituída nas normativas de constituição do Sistema Único de Saúde, ainda encontra desafios para efetivação em âmbito local, especialmente em territórios urbanos marcados por violência e pobreza. O ensaio objetivou apresentar e discutir aspectos de uma experiência de gestão participativa em um território vulnerável, mediada pela Atenção Primária à Saúde. Essa experiência de cogestão da saúde foi desenvolvida entre 2009 e 2013 em Manguinhos, no município do Rio de Janeiro. A partir do relato de gestores e de materiais técnicos produzidos, analisou-se a implementação de estratégias, tais como a mobilização para criação de um conselho gestor intersetorial local e aquelas de informação, educação e comunicação em saúde suportadas por apoiadores institucionais e pelas equipes de saúde da família. Concluiu-se que práticas gerenciais e sanitárias democráticas podem ser desenvolvidas por meio de tecnologias sociais, que valorizem a gestão participativa e compartilhada entre trabalhadores-usuários-gestão.

ABSTRACT Participatory management, although instituted in the norms of the constitution of the Brazilian Universal Health System (SUS), still faces challenges to be effective in practice at a local level, especially in complex urban territories, aiming at community strengthening and social participation. This essay aims to present and discuss aspects of a participatory management experience in a vulnerable territory, mediated by Primary Health Care. This experience of health co-management was developed between 2009 and 2013 in Manguinhos, a municipality of Rio de Janeiro. From the managers' reports and the technical materials produced, the implementation of strategies analyzed were the mobilization to create a local intersectoral management council and those of information, education, and communication in health supported by institutional supporters and by the family health teams. We concluded that democratic managerial and sanitary practices can be developed through social technologies, which value participative and shared management among workers-users-management.

O cuidado às Pessoas Vivendo com HIV/Aids na Atenção Primária à Saúde na cidade do Rio de Janeiro: uma avaliação de implantação / Care for People Living With HIV/AIDS in Primary Health Care in the city of Rio de Janeiro: an implementation evaluation

RESUMO Objetivou-se realizar uma avaliação de implantação do modelo descentralizado de cuidado às Pessoas Vivendo com HIV/Aids (PVHA) no Município do Rio de Janeiro (MRJ) mediante análise do contexto que propiciou a intervenção e análise do grau de implantação ao fim do período estudado (2013-2016). Nesses anos, substituiu-se a atenção centrada no infectologista pelo manejo focado na Atenção Primária à Saúde (APS), no contexto de fortalecimento da Estratégia Saúde da Família. A pesquisa utilizou entrevistas com gestores e análise de dados secundários para estudar o contexto gerencial da saúde no MRJ e sua influência sobre a construção do modelo descentralizado, assim como as características desse modelo e o grau de sua implantação. A análise de contexto evidenciou a influência das normativas nacionais sobre a reforma da APS no município, e desta sobre a proposta de cuidado descentralizado, bem como as tensões entre atores do processo, especialmente gestores, médicos da APS, infectologistas e PVHA. Como características do modelo descentralizado, destacaram-se ampliação de acesso, promoção da integralidade e coordenação do cuidado. Quanto ao grau de implantação, concluiu-se que esta havia progredido heterogeneamente, avançando mais nas áreas de prevenção, diagnóstico e assistência farmacêutica, e menos em atenção integral e coordenação do cuidado.

ABSTRACT This article aimed to evaluate the implementation of a decentralized care model for People Living With HIV/AIDS (PLWHA) in the city of Rio de Janeiro, by analyzing the context that enabled it and the degree of its implementation at the end of the time frame studied (2013-2016). During this period, infectologist-centered HIV/AIDS care was replaced by one centered in Primary Health Care (PHC), in the context of strengthening the Family Health Strategy. By interviewing administrators and analyzing secondary data, we studied the process from city health managers' viewpoint, described its main characteristics and the degree to which decentralization measures were implemented. As a result, we observed how national guidelines influenced the implementation of changes in the municipal PHC structure, especially in the restructuring of HIV care, and the tensions among key players (administrators, PHC doctors, infectologists, and PLWHA). Among the characteristics of the new model, increasing healthcare access, enhancing integrality and coordination of care were features most commonly cited in the interviews. Finally, the degree of implementation of the decentralization policy was found to be heterogeneous, being more advanced in the fields of prevention, diagnosis and access to medication, and less in comprehensive care and coordination of care.

[Food consumption and anthropometry related to the frailty syndrome in low-income community-living elderly in a large city]. / Consumo alimentar e antropometria relacionados à síndrome de fragilidade em idosos residentes em comunidade de baixa renda de um grande centro urbano.

The aim of this study was to describe anthropometric and food intake data related to the frailty syndrome in the elderly. This was a cross-sectional study in individuals ≥ 60 years of age in a household survey in the Manguinhos neighborhood of Rio de Janeiro, Brazil (n = 137). Frailty syndrome was diagnosed according to Fried et al., anthropometric measures were taken, and a food frequency questionnaire was applied and the results compared to Brazilian Ministry of Health guidelines. In the pre-frail and frail groups, body mass index and measures of central adiposity showed higher levels, while lean muscle parameters showed lower values, proportional to the syndrome's gradation. Frail elderly consumed higher amounts of grains and lower amounts of beans and fruit; pre-frail elderly consumed more vegetables, dairy products, and high-sugar and high-fat foods; the two groups consumed similar amounts of meat. Thus, diagnosis of the syndrome, anthropometric evaluation, and dietary assessment should be included in health policies for the elderly, since they assist in early identification of risk and favor interventions for disease prevention and health and nutritional promotion.

Training of professionals in post-graduation courses in public health and primary healthcare in the municipality of Rio de Janeiro, Brazil. / A formação de profissionais na pós-graduação em saúde pública e atenção primária à saúde no município do Rio de Janeiro, Brasil.

UNLABELLED: This paper examines post-graduation professional training and qualification courses in the fields of public health and primary healthcare. Its aim is to reflect on the construction and methodological proposal of two courses given by ENSP/Fiocruz in partnership with the Municipality of Rio de Janeiro, over the years 2010 to 2014: The Professional Master's Degree in Primary Healthcare (MPAPS), and Specialization in Public Health. METHODOLOGY: Systematization of academic documents of the courses, with preparation of emerging analytical categories (theoretical management-interface history, field of pedagogy). RESULTS/DISCUSSION: Two classes of the MPAPS course (n=24 students per group) and five of the Specialization course (average 30 per group) were held in the period, with approval rates at the 90%-80% level, with curriculum structure adjusted to the local situation. As challenges that were implemented, we highlight: 1) On the epistemological level: development of competencies for professional training that would produce results coherent with health, as social/cultural production; 2) from the learning point of view: preparation of dynamics that give value to the students, their social-cultural context and experiences; 3) work environments and relationships, bringing their structured analysis into the learning environment.

Comparação entre autoimagem e índice de massa corporal entre crianças residentes em favela do Rio de Janeiro, 2012 / Comparación entre la autoimagen y el índice de masa corporal entre los niños que viven en una favela en Rio de Janeiro, Brasil, 2012 / Comparison between self-image and body mass index among children living in a slum in Rio de Janeiro, Brazil, 2012

Objetivo: Analisar a concordância/discrepância entre autoimagem corporal e classificação do índice de massa corporal (IMC), segundo tipo de alimentação e influências do ambiente. Métodos: Análise transversal de 195 crianças pré-púberes (≥5 anos), atendidas na Atenção Primária à Saúde (APS), Manguinhos, Rio de Janeiro, Brasil. O IMC foi classificado conforme escore-z. Avaliou-se a autoimagem pela escala de silhuetas para crianças. Estimou-se a associação entre as covariáveis e subestimação/superestimação do IMC em relação à autoimagem, em modelo multinomial. Resultados: Crianças com sobrepeso subestimaram seu IMC, em comparação com a autoimagem, em maior proporção (58,6%) que aquelas com obesidade (22,0%) ou com eutrofia (49,0%). Essa dissociação correlacionou-se com a participação no programa de transferência de renda (RC=2,01 - IC95% 1,04;3,90) e com o consumo diário de alimentos açucarados (RC=3,88 - IC95% 1,05;14,39). Conclusão: A subestimação do IMC entre as crianças com excesso de peso deve ser considerada pela APS, visando aperfeiçoar as práticas de intervenção.

Objetivo: Verificar la correspondencia/divergencia entre autoimagen e índice de masa corporal (IMC), según variables relacionadas al tipo de alimentación e influencia del ambiente. Métodos: Análisis transversal de 195 niños prepúberes (≥5 anos), atendidos en la Atención Primaria de Salud (APS). Se utilizó la clasificación del IMC basada em la puntuación z de la Organización Mundial de la Salud. La autoimagen se evaluó según la escala de silueta validada para niños. Se estimó la asociación de covariables con el resultado de la subestimación/sobreestimación del estado nutricional en modelo multinomial. Resultados: Los niños con sobrepeso subestimaron su IMC, en comparación con la autoimagen, en una mayor proporción (58.6%) que los obesos (22.0%) y eutróficos (49.0%). Esta disociación de la representación se asoció con la participación en el programa de transferencia de renta (odds ratio [OR] = 2,01 - IC95% 1,04;3,90) y con el consumo diario de dulces (OR=3,88 - IC95% 1,05;14,39). Conclusión: La subestimación del IMC de los niños con sobrepeso debe tenerse en cuenta para la mejor intervención en las prácticas de atención primaria de salud.

Objective: To analyze agreement/discrepancy between body self-image and Body Mass Index (BMI), according to variables related to type of food and environment influence. Methods: This was a cross-sectional analysis of 195 prepubescent children (≥5 anos), attending a Primary Health Care service in Manguinhos, Rio de Janeiro. Z-scores were applied to classify BMI. Self-image was collected using the figure rating scale (silhouettes) validated for children. A multinomial model was used to estimate covariate association with the underestimated/overestimated BMI outcome in relation to self-image. Results: Overweight children underestimated their BMI, as compared with self-image, more often (58.6%) than obese children (22.0%) and children with adequate BMI (49.0%). This dissociation was correlated to participation in a cash transfer program (OR=2.01 - 95%CI 1.04;3.90) and daily consumption of sugar-sweetened foodstuffs (OR=3.88 - 95%CI 1.05;14.39). Conclusion Underestimation of BMI among overweight children should be taken into account by Primary Health Care services, in order to enhance intervention practices.

Atenção integral à saúde do adolescente pela Atenção Primária à Saúde no território brasileiro: uma revisão integrativa / Comprehensive health care of teenagers by the Primary Health Care in the Brazilian territory: an integrative review / Atención integral a la salud del adolescente por la Atención Primaria de la Salud en el territorio brasileño: una revisión integradora

A adolescência, fase de transformações biopsicossociais, requer da Atenção Primária à Saúde (APS) um modelo de cuidado à saúde abrangente, integral e promotor da saúde e da autonomia, aspectos abordados nesta revisão. Objetivou-se sistematizar experiências de cuidado ao adolescente pela APS. Realizou-se uma revisão integrativa nas bases de dados da Biblioteca Virtual em Saúde e Biblioteca Eletrônica Científica Online, selecionando-se 21 artigos publicados entre 2008 a 2019. Os dados foram interpretados pela análise temática de conteúdo. Observaram-se estigmas no cuidado ao adolescente; lacunas na formação profissional; acolhimento centrado na enfermagem; fragilidades dos vínculos; escassez de recursos estruturais e humanos; ações educativas, porém normativas; fragmentação das práticas; e barreiras de acesso à rede de saúde e intersetorial. Conclui-se, portanto, que, para alcançar um cuidado ampliado, é preciso repensar as práticas e dar voz ao adolescente.(AU)

Adolescence, a phase of biopsychosocial transformations, requires a comprehensive primary health care model that promotes health and autonomy, aspects covered in this review. The objective was to systematize the experiences of care of teenagers by the Primary Health Care. An integrative review was conducted on the Virtual Health Library (BVS) and Scientific Electronic Library Online databases, selecting 21 published papers from 2008 to 2019. Data were interpreted through the thematic content analysis. The following were observed in teenager care: stigmata; gaps in professional education; nursing-focused reception; weakness of bonds; lack of structural and human resources; educational but normative actions; fragmentation of practices; and barriers to the health and intersectoral networks. Therefore, the conclusion is that in order to achieve an expanded care it is necessary to rethink practices and give voice to teenagers.(AU)

La adolescencia, fase de transformaciones biopsicosociales, requiere de la Atención Primaria de la Salud (APS), un modelo de cuidado a la salud incluyente, integral y promotor de la salud y de la autonomía, aspectos abordados en esta revisión. El objetivo fue sistematizar experiencias de cuidado al adolescente por parte de la APS. Se realizó una revisión integradora en las bases de datos Biblioteca Virtual en Salud y Biblioteca Electrónica Científica Online, seleccionándose 21 artículos publicados de 2008 a 2019. Los datos se interpretaron por el análisis temático de contenido. Se observaron estigmas en el cuidado del adolescente; lagunas en la formación profesional; acogida centrada en la enfermería; fragilidades de los vínculos; escasez de recursos estructurales y humanos; acciones educativas, pero normativas; fragmentación de las prácticas y barreras de acceso a la Red de Salud e Intersectorial. Se concluyó, por lo tanto, que para alcanzar un cuidado ampliado es preciso repensar las prácticas y dar voz al adolescente.(AU)

Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo / The professional path of postgraduates of a professional master's degree in primary health care in the municipality of Rio de Janeiro, Brazil: an evaluative study

Resumo Visando estudar a trajetória de egressos de duas turmas de Mestrado Profissional realizou-se estudo exploratório, com questionário eletrônico on line, anônimo, com quatro blocos: pessoal; atividade profissional atual; relação do curso-situação profissional e ainda perguntas abertas para pontos positivos/negativos. Resultados: a maioria mantinha-se na área da atenção primária e em serviços públicos; na assistência à saúde e muitos como preceptores; desenvolviam atividade no trabalho relacionada ao curso e 75% relatam alto o impacto do curso. Menor efeito foi percebido na remuneração e maiores na formação profissional, nas redes de relações; no crescimento pessoal e no trabalho. As estratégias pedagógicas ativas foram bem avaliadas. Conclusão: metodologia de avaliação factível e aplicável para sistemas de acompanhamento de egressos; permite conhecer a relação formação e trabalho.

Abstract A four-block exploratory study was conducted with an electronic online, anonymous questionnaire to study the path of postgraduates from two professional master's degree classes, as follows: personal, current professional activity, course-professional situation relationship, and open-ended questions for positive/negative points. Results: Most of them remained in the primary care area and public services; in health care and as tutors; developed a course-related work activity, and 75% reported a high impact of the course. A lower effect was perceived in the remuneration. A higher effect was noted in the professional training, the networks of relationships, personal growth, and work. The active pedagogical strategies were well evaluated. Conclusion: This is a feasible and applicable evaluation method for graduate monitoring systems, and it allows knowing the relationship between training and work.

Análise documental sobre decisão compartilhada nas diretrizes clínicas de câncer / Shared decision-making in clinical cancer guidelines / Análisis documental sobre la toma de decisiones compartida en las directrices clínicas para el cáncer

Resumo A decisão compartilhada é processo colaborativo que inclui preferências individuais na elaboração do plano de cuidados. Este estudo examina como esse tipo de decisão é contemplado nas diretrizes terapêuticas para o câncer do Sistema Único de Saúde, buscando nos sites do Instituto Nacional de Câncer e da Comissão Nacional de Incorporação de Tecnologias documentos que citassem a participação do paciente. Foram analisados 29 documentos e, dentre eles, dez abordavam decisão compartilhada ou ideias relacionadas. Esses textos tratavam da possibilidade de rastrear alguns tipos de câncer e estabeleciam critérios para a interrupção do tratamento. Os resultados revelaram que ainda há grandes desafios para promover a autonomia, o respeito a valores individuais e a parceria em ambientes clínicos.

Abstract Shared decision-making is a collaborative process that includes patient preferences in the care planning process. This study aimed to analyze how the shared decision-making is considered in the cancer guidelines of the Brazilian Unified Health System through a research of documents about patients' participation on the databases of the National Cancer Institute and National Commission for the Incorporation of Technologies. We analyzed 29 documents, and 10 of them presented an approach for shared decision-making or ideas related to the topic. These documents addressed the possibility of screening some types of cancer and established criteria for interrupting the treatment. The results show the great challenges that still exist to promote autonomy, and to respect individual values and partnership in clinical settings.

Resumen La toma de decisiones compartida es un proceso colaborativo que incluye preferencias individuales en la elaboración del plan de cuidados. Este estudio buscó examinar la manera en que este tipo de decisión es contemplado en las directrices terapéuticas para el cáncer del Sistema Único de Salud de Brasil, buscando, en los sitios electrónicos del Instituto Nacional del Cáncer y de la Comisión Nacional de Incorporación de Tecnologías, documentos que mencionaran la participación del paciente. Se analizaron 29 documentos y, entre ellos, diez abordaban la toma de decisiones compartida o ideas relacionadas. Estos textos abordaban la posibilidad de rastrear algunos tipos de cáncer y establecían criterios para la interrupción del tratamiento. Los resultados revelaron que aún hay grandes desafíos para promover la autonomía, el respeto por los valores individuales y la coparticipación en entornos clínicos.

[Growth and nutritional status in a probabilistic sample of schoolchildren from Rio de Janeiro, 1999]. / Crescimento e estado nutricional em amostra probabilística de escolares no Município do Rio de Janeiro, 1999.

Growth and nutritional status were assessed in a probabilistic sample of public schoolchildren (1,705 girls and 1,682 boys) in the city of Rio de Janeiro in 1999. Nutritional status of the under-10-year group was assessed by z < -2 (undernutrition) for body mass for height and height for age and by z > +2 for body mass for height (overweight). For children over 10, the 5th and 85th percentiles of body mass index for age were used to assess underweight and overweight, respectively. Prevalence rates of overweight and obesity according to the International Obesity Task Force criteria were also calculated. Prevalence rates for undernutrition were below expected for the reference population. Prevalence of overweight was approximately 18% and 14% for girls and boys, respectively, and obesity was 5% for both sexes. The results of the present study are similar to findings from population-based surveys in Brazil: low prevalence of undernutrition and high prevalence of overnutrition.

Health-related and socio-demographic factors associated with frailty in the elderly: a systematic literature review.

Frailty is a syndrome that leads to practical harm in the lives of elders, since it is related to increased risk of dependency, falls, hospitalization, institutionalization, and death. The objective of this systematic review was to identify the socio-demographic, psycho-behavioral, health-related, nutritional, and lifestyle factors associated with frailty in the elderly. A total of 4,183 studies published from 2001 to 2013 were detected in the databases, and 182 complete articles were selected. After a comprehensive reading and application of selection criteria, 35 eligible articles remained for analysis. The main factors associated with frailty were: age, female gender, black race/color, schooling, income, cardiovascular diseases, number of comorbidities/diseases, functional incapacity, poor self-rated health, depressive symptoms, cognitive function, body mass index, smoking, and alcohol use. Knowledge of the complexity of determinants of frailty can assist the formulation of measures for prevention and early intervention, thereby contributing to better quality of life for the elderly.

Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro / The invisible urban dwellers: the stigma of People Living in the Streets in Rio de Janeiro

RESUMO Evidencia-se, no Brasil e em outros países da América Latina, o aumento da população de rua, muitos dos quais são usuários de crack. Essa população sofre de estigmas vinculados a uma percepção de fragilidade do caráter, como vontade fraca para interromper o uso da droga e como pessoa perigosa na medida em que é temida pela sociedade, visto que é percebida como agressora. Isso traz consequências como o isolamento social, a perda da autoestima, dificuldade de acesso aos serviços de saúde que provocam o afastamento da busca de suporte social e de saúde por parte do usuário, agravando suas condições de vida. Como metodologia, foram realizadas 48 entrevistas com trabalhadores e usuários das equipes de Consultório na Rua nas quais foi possível reconhecer o estigma internalizado pelas pessoas que se reconhecem como portadoras das características negativas que lhes são imputadas, assim como percepção dos profissionais de saúde da estigmatização sofrida por essa população. O desvelamento dos estigmas e sua análise podem auxiliar na reorientação de um conjunto de práticas de cuidado que garantam direitos básicos de saúde, educação, moradia e trabalho constituintes da cidadania, de modo a fomentar processos de democratização e de inclusão social dessa população estigmatizada em situação de extrema vulnerabilidade.

ABSTRACT People living in the streets, many of whom are crack users, are on the rise in Brazil and other Latin American countries. Such a population suffers from stigmas linked to a perception of fragile character, such as weak willpower to stop drug use, and a dangerous individual feared by society because perceived as an aggressor. The consequences of those stigmas are social isolation, loss of self-esteem, difficulty in accessing health services, which make users withdraw from social and health support, deteriorating their living conditions. Forty-eight interviews were conducted with workers and users of the Street Clinic (Consultório na Rua), which revealed the stigma internalized by people recognized as carriers of the negative traits assigned to them, as well as health professionals' perception of the stigma suffered by such population. The unveiling of stigmas and their analysis can reorient a set of care practices to ensure fundamental rights in health, education, housing, and work, which underpin citizenship, to promote the democratization and social inclusion process of the stigmatized people living in a situation of extreme vulnerability.

A dimensão do cuidado pelas equipes de Consultório na Rua: desafios da clínica em defesa da vida / The dimension of care by the 'Street Clinic' team: challenges of the clinic in defense of life

RESUMO O estudo objetivou analisar a produção de cuidados primários à saúde à população em situação de rua, prestados por equipes de Consultório na Rua (eCR) no contexto de uma metrópole brasileira, identificando potencialidades e dificuldades. Estudo de caso, de abordagem qualitativa, considerando o universo das sete equipes no ano 2016/2017, com observação direta do trabalho e realização de entrevistas semiestruturadas com profissionais de várias categorias (n=34), com análise temática de conteúdo. Observou-se que as eCR atuavam com escopo ampliado e integral de ações, cuidados clínicos e intersetoriais, nos espaços das ruas e nos serviços, em trabalho de equipe integrado. Organizavam-se com flexibilidade, baixa exigência, busca ativa nos territórios, de forma itinerante, no tempo oportuno, imediato, construção de planos terapêuticos compartilhados, que promoviam autonomia, baseados na redução de danos. Dificuldades eram inerentes às vulnerabilidades e complexidades dos casos, à fragmentação da rede de atenção, à qualidade dos instrumentos para registro em saúde e à carência de recursos estruturais (transporte, insumos para ações de promoção da saúde). Concluiu-se que o cuidado se sustentava na dimensão ético-política, usuário-centrado, na solidariedade e na defesa da vida.

ABSTRACT The study aimed to analyze the production of Primary Health Care to people living in the streets, provided by Street Office (eCR) teams in the context of a Brazilian metropolis, identifying potentialities and difficulties. This is a qualitative case study considering the universe of the seven teams in the 2016-2017 period, with direct observation of the work and conducting semi-structured interviews with professionals from various categories (n=34), with thematic content analysis. We observed that the eCR operated with an enlarged and comprehensive scope of actions, clinical and intersectoral care, in street spaces and services, through integrated teamwork. They were organized with flexibility, low demand, active search in the territories, in an itinerant way, timely, and immediately, with the construction of shared therapeutic plans, which promoted autonomy, based on harm reduction. Difficulties were inherent to the vulnerabilities and complexities of the cases, the fragmentation of the health care network, the quality of the instruments for health registration and the lack of structural resources (transportation and inputs for health promotion actions). We concluded that care was sustained in the ethical-political, user-centered dimension, in solidarity and in the defense of life.

Vínculo longitudinal na Saúde da Família: construção fundamentada no modelo de atenção, práticas interpessoais e organização dos serviços / Longitudinality in Family Health: construction based on the care model, interpersonal practices and service organization

Resumo O vínculo longitudinal (VL) é um atributo essencial da Atenção Primária à Saúde (APS), com um papel fundamental no processo de trabalho em saúde da família e no cuidado. Apresenta-se a descrição dos sentidos sobre o VL para profissionais de saúde e como são desenvolvidas tais práticas no modelo da Saúde da Família. Trata-se de uma pesquisa qualitativa, exploratória, utilizando o método de análise de conteúdo de Bardin. Como resultado, foi encontrada a valorização da relação sistêmica do vínculo em um Modelo da APS que abarca a porta de entrada, integralidade e coordenação, materializando a responsabilização da equipe pelo cuidado de indivíduos, famílias e comunidades; o vínculo como prática organizacional, sendo utilizado o trabalho em equipe, práticas de educação em saúde e visita domiciliar como estratégias para o cuidado e a afinidade interpessoal como fortalecedor da empatia e da relação de confiança entre o profissional de saúde e o usuário, auxiliando na construção de autonomia dos doentes crônicos. O VL é um dispositivo presente e relevante no processo de trabalho em saúde da família, porém ameaçado pelo excesso de trabalho e burocracia e pela falta de tempo para o desenvolvimento das atividades.

Abstract Longitudinality is an essential attribute of Primary Health Care (PHC), with a fundamental role in the work process in family health and care. We present a description of the meanings about the longitudinality for health professionals and how this practice is developed in the Family Health model. This is a qualitative, exploratory research, using the Bardin content analysis method. As a result, it was found the valorization of the systemic relationship of longitudinality in an PHC Model that covers the door of entry, integrality and coordination, materializing the responsibility of the team for the care of individuals, families and communities; longitudinality as organizational practice, using teamwork, health education practices and home visits as strategies for care; and the interpersonal relationship reinforcing the empathy and the trust in the relationship between the health professional and the patient, assisting in the construction of autonomy of the chronic patients. Longitudinality is a present and relevant device in the family health work process, but it is threatened by overwork, bureaucracy and lack of time for the development of activities.