Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: What can (and should) improve?

The article describes the temporal evolution of prenatal quality indicators in the primary health care network in Brazil and investigates regional differences. This study used data from the external evaluation of Brazil's National Program for Improving Primary Care Access and Quality (PMAQ) with health teams participating in Cycles I, II and III of the Program, carried out respectively in 2012, 2013/14 and 2017/18. The number of visits, physical examination procedures, guidelines and request for laboratory tests were investigated. There was a positive evolution for tests-HIV, syphilis, blood glucose and ultrasound, and for all tests, guidance on feeding and weight gain of the baby and examination of the oral cavity. The indicators that performed the worst were: performance of tetanus vaccine, six or more visits, receiving guidance on exclusive breastfeeding and care for the newborn, and the procedures-all, measurement of uterine height, gynecological exam and cervix cancer prevention. These changes had a varied behavior between the regions of the country.

Prevalence of dementia and cognitive impairment with no dementia in a primary care setting in southern Brazil.

BACKGROUND: Cognitive decline is a common condition, but is still underrepresented in studies conducted in developing countries. OBJECTIVE: To calculate the prevalence of cognitive decline and depression in an elderly community-dwelling population in a city in southern Brazil. METHODS: We calculated the prevalences of dementia, cognitive impairment with no dementia (CIND) and symptoms of depression in an elderly population relying on the public healthcare system. This epidemiological study in Pelotas, Brazil, was conducted within the primary care setting. It included 299 older adults (mean age = 69.75 ± 7.6 years) who presented low levels of education (mean = 4.16 ± 3.17 years of education). They underwent cognitive screening and their medical records were analyzed. RESULTS: Among these older adults, 142 (47.5%) presented cognitive decline: 104 (34.8%) matching the cognitive criteria for CIND and 38 (12.7%) matching the cognitive criteria for dementia. Among all the individuals who completed the cognitive screening, 141 (48.4%) were positive for symptoms of depression, of whom 99 (34%) did not have any previous diagnosis in their medical records. CONCLUSION: There was high prevalence of cognitive impairment among these older adults in a primary care setting. A large number of older adults were found to have symptoms of depression without any diagnosis.

Structure for the work and composition of Family Health Support Unit teams: national survey - Program for Improving Primary Health Care Access and Quality (PMAQ), 2013. / Estrutura para o trabalho e composição de equipes do Núcleo de Apoio à Saúde da Família: pesquisa nacional - Programa de Melhoria do Acesso e da Qualidade (PMAQ), 2013.

OBJECTIVE: to describe the structure of Family Health Support Unit (FHSU) teams with regard to physical space, training received, continuing education and professionals that support Primary Health Care (PHC) teams in Brazil, in 2013. METHODS: this is a descriptive study using data from the external evaluation stage of the Program for Improving Primary Health Care Access and Quality (PMAQ). RESULTS: the 1,773 FHSU teams mainly used shared clinics at primary health care centers (85.7%); 63.4% of professionals were offered specific training when they started work at their FHSU, while 67.4% were offered continuing education; the teams received support mainly from physiotherapists (87.4%) and Physical Education professionals (87,0%). CONCLUSION: the structure available for FHSU teams is in accordance with the guidelines; some FHSU professionals have not received any specific training for the job.

Family Health Support Center: health promotion, physical activity, and chronic diseases in Brazil - national PMAQ survey 2013. / Núcleo de Apoio à Saúde da Família: promoção da saúde, atividade física e doenças crônicas no Brasil - inquérito nacional PMAQ 2013.

OBJECTIVE: to describe reported health promotion actions directed towards chronic non-communicable disease (CNCD) patients, the support of physical education professionals (PEP) and the implementation of actions to promote body practices and physical activity (BPPA) by the Family Health Support Center (FHSC) teams, according to Brazilian municipality context variables. METHODS: this was a cross-sectional study, forming part of the 2013/2014 National Primary Health Care Access and Quality Improvement Program (PMAQ), by means of interviews with FHSC professionals. RESULTS: the action most reported by the teams was evaluation and rehabilitation of psychosocial conditions (90.8%); promotion of BPPA was the sixth most performed action, and was more prevalent in the Brazilian Southeast region (89.6%), in medium-sized municipalities (88.7%), with medium human development index (HDI) (86.7%); PEP provided support to 87% of the teams. CONCLUSION: FHSC were found to make an important contribution to BPPA.

Núcleo de Apoio à Saúde da Família: promoção da saúde, atividade física e doenças crônicas no Brasil - inquérito nacional PMAQ 2013 / Núcleo de Apoyo a la Salud de la Familia: promoción de la salud, actividad física y enfermedades crónicas en Brasil - encuesta nacional PMAQ 2013 / Family Health Support Center: health promotion, physical activity, and chronic diseases in Brazil - national PMAQ survey 2013

Objetivo: descrever o relato de ações de promoção da saúde dirigidas a portadores de doenças crônicas não transmissíveis, o apoio do profissional de educação física (PEF) e a realização da ação de promoção de práticas corporais e atividade física (PCAF) pelas equipes do Núcleo de Apoio à Saúde da Família (NASF), segundo variáveis de contexto dos municípios do Brasil. Métodos: estudo transversal, integrante do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ) 2013/2014, mediante entrevistas a profissionais do NASF. Resultados: a ação mais relatada pelas equipes foi a avaliação e reabilitação de condições psicossociais (90,8%); a ação de promoção de PCAF foi a sexta mais realizada e teve maior prevalência no Sudeste brasileiro (89,6%), em municípios de médio porte (88,7%), com índice de desenvolvimento humano (IDH) médio (86,7%); o PEF apoiou 87% das equipes. Conclusão: revelou-se importante contribuição do NASF para as ações de PCAF.

Objetivo: describir el relato de acciones de promoción de la salud dirigidas a portadores de enfermedades crónicas no transmisibles (ECNT), el apoyo del profesional de educación física (PEF) y la realización de la acción de promoción de prácticas corporales y actividad física (PCAF) por los equipos del Núcleo de Apoyo a la Salud de la Familia (NASF), según variables de contexto de los municipios de Brasil. Métodos: estudio transversal, integrante del Programa Nacional de Mejoría del Acceso y de la Calidad de la Atención Básica (PMAQ) 2013/2014, con entrevistas a profesionales del NASF. Resultados: la acción más relatada por los equipos fue la evaluación y la rehabilitación de condiciones psicosociales (90,8%); la acción de promoción de PCAF fue la sexta más realizada, tuvo mayor prevalencia en el Sudeste brasileño (89,6%), en municipios de mediano porte (88,7%), con índice de desarrollo humano (IDH) medio (86,7%); el PEF apoyó 87% de los equipos. Conclusión: se reveló una importante contribución del NASF a acciones de PCAF.

Objective: to describe reported health promotion actions directed towards chronic non-communicable disease (CNCD) patients, the support of physical education professionals (PEP) and the implementation of actions to promote body practices and physical activity (BPPA) by the Family Health Support Center (FHSC) teams, according to Brazilian municipality context variables. Methods: this was a cross-sectional study, forming part of the 2013/2014 National Primary Health Care Access and Quality Improvement Program (PMAQ), by means of interviews with FHSC professionals. Results: the action most reported by the teams was evaluation and rehabilitation of psychosocial conditions (90.8%); promotion of BPPA was the sixth most performed action, and was more prevalent in the Brazilian Southeast region (89.6%), in medium-sized municipalities (88.7%), with medium human development index (HDI) (86.7%); PEP provided support to 87% of the teams. Conclusion: FHSC were found to make an important contribution to BPPA.

Estrutura para o trabalho e composição de equipes do Núcleo de Apoio à Saúde da Família: pesquisa nacional - Programa de Melhoria do Acesso e da Qualidade (PMAQ), 2013 / Estructura para el trabajo y composición de equipos del Núcleo de Apoyo a la Salud de la Familia, Brasil: encuesta nacional - Programa de Mejora del Acceso y la Calidad (PMAQ), 2013 / Structure for the work and composition of Family Health Support Unit teams: national survey - Program for Improving Primary Health Care Access and Quality (PMAQ), 2013

Objetivo: descrever a estrutura das equipes dos Núcleos de Apoio à Saúde da Família (NASF) quanto a espaços físicos, formação recebida, educação permanente e profissionais que apoiam as equipes de Atenção Básica à Saúde no Brasil, em 2013. Métodos: estudo descritivo, com dados da fase de avaliação externa do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Resultados: as 1.773 equipes de NASF utilizam, principalmente, consultórios compartilhados na unidade básica de saúde (UBS) (85,7%); para 63,4% dos profissionais, foi oferecida formação específica quando iniciaram o trabalho no NASF, e para 67,4%, educação permanente; as equipes receberam o apoio principalmente de fisioterapeutas (87,4%) e profissionais de educação física (87,0%). Conclusão: as equipes de NASF têm estrutura de acordo com o preconizado nas diretrizes; há profissionais do NASF que não receberam formação específica para o trabalho.

Objetivo: describir la estructura de los equipos de Núcleos de Apoyo a la Salud de la Familia (NASF) en relación a espacios físicos, formación recibida, educación permanente y profesionales que apoyan a los equipos de Atención Básica de Salud (ABS) en Brasil, el 2013. Métodos: estudio descriptivo, transversal, con datos de la fase de evaluación externa del Programa de Mejora del Acceso y la Calidad de la Atención Básica (PMAQ). Resultados: los 1.773 equipos de NASF utilizan principalmente consultorios compartidos en la unidad básica de salud (UBS) (85,7%); para el 63,4% de los profesionales se ofreció formación específica cuando iniciaron el trabajo en el NASF, y para el 67,4%, educación permanente; los equipos recibieron el apoyo de fisioterapeutas (87,4%) y de profesionales de Educación Física (87%). Conclusión: los equipos del NASF tienen estructura de acuerdo con lo preconizado en las directrices del NASF; hay profesionales del NASF que no recibieron entrenamiento específico para el trabajo.

Objective: to describe the structure of Family Health Support Unit (FHSU) teams with regard to physical space, training received, continuing education and professionals that support Primary Health Care (PHC) teams in Brazil, in 2013. Methods: this is a descriptive study using data from the external evaluation stage of the Program for Improving Primary Health Care Access and Quality (PMAQ). Results: the 1,773 FHSU teams mainly used shared clinics at primary health care centers (85.7%); 63.4% of professionals were offered specific training when they started work at their FHSU, while 67.4% were offered continuing education; the teams received support mainly from physiotherapists (87.4%) and Physical Education professionals (87,0%). Conclusion: the structure available for FHSU teams is in accordance with the guidelines; some FHSU professionals have not received any specific training for the job.

Prevalência de absenteísmo em consultas médicas em unidade básica de saúde do sul do Brasil / Prevalence of absenteeism in medical appointments in a basic health unit in the south of Brazil / Prevalencia de absentismo en consultas médicas en una unidad básica de salud en el sur de Brasil

Introdução: O absenteísmo às consultas médicas previamente marcadas é um problema que interfere com a efetividade dos serviços de saúde. Neste contexto, a reorganização da agenda dos profissionais é central no sentido de garantir o acolhimento e a continuidade do cuidado. Objetivo: Descrever a prevalência de absenteísmo a partir da agenda de atendimento médico de um serviço de Atenção Primária à Saúde (APS) de ensino de graduação e pós-graduação do município de Pelotas, no estado do Rio Grande do Sul. Métodos: Foi realizado um estudo transversal com a totalidade dos agendamentos de um mês de atendimento de cada estação do ano, entre julho de 2016 e abril de 2017. Os dados foram coletados da agenda física local, digitados e analisados em planilha Excel®. Resultados: De 3.131 consultas médicas agendadas, foram computadas 598 faltas, resultando em uma prevalência de absenteísmo de 19,2% (IC95% 17,7-20,8). Dos 153 turnos de atendimento, em apenas 2% não ocorreram ausências e, entre os demais, a prevalência variou de 4,2% a 45%. Na distribuição do absenteísmo entre os sete grupos de consultas pesquisados destacaram-se os 62,3% de absenteísmo para os atendimentos de clínica geral e os 12,2% para a realização de exame citopatológico de colo uterino. Conclusão: Os resultados mostram uma elevada prevalência de absenteísmo, especialmente nas consultas de clínica médica, o que pode acarretar problemas tanto para a continuidade do cuidado, especialmente aos usuários da clínica geral, quanto para o ensino médico na APS. Este achado é superior ao encontrado por Tristão et al. em um estudo brasileiro em serviços de saúde ambulatoriais, e inferior ao resultado descrito por Izecksohn e Ferreira em um Centro de Saúde Escola. Os autores sugerem a necessidade de mudanças organizacionais na oferta de consultas objetivando ampliar o acesso e facilitar a adesão às consultas agendadas, de forma a garantir a longitudinalidade do cuidado.

Introduction: The absenteeism at scheduled medical appointments is a problem that interferes with the effectiveness of health services. In this context, the reorganization of the professionals schedule is central in ensuring the reception and continuity of care. Objective: To describe the prevalence of absenteeism from the health care agenda of a primary health care service (APS) for undergraduate and postgraduate education in the municipality of Pelotas, state of Rio Grande do Sul. Methods: A cross-sectional study was carried out with all the schedules of one month of medical appointments in each season between July 2016 and April 2017. The data were collected from the local appointment system, typed and analyzed in an Excel® worksheet. Results: Of the 3,131 scheduled medical appointments, 598 absences were recorded, resulting in a prevalence of absenteeism of 19.2% (95% CI, 17.7-20.8). Of the 153 care shifts in only 2%, there were no absences and, among others, the prevalence ranged from 4.2% to 45%. In the distribution of absenteeism among the seven groups of consultations surveyed, 62.3% of absenteeism was observed for general practitioner and 12.2% for the accomplishment of cytopathological exam of the uterine cervix. Conclusion: The results show a high prevalence of absenteeism, especially in medical clinic visits, which can lead to problems both for continuity of care, especially for general practitioners, and for medical teaching in APS. This finding is superior to that found by Tristão et al. in a Brazilian study on outpatient health services, and lower than the result described by Izecksohn and Ferreira in a School Health Center. The authors suggest the need for organizational changes aiming at increasing access and facilitating adherence to scheduled appointments, in order to guarantee the longitudinality of care.

Introducción: El absentismo a las consultas previamente marcadas es un problema que interfiere con la efectividad de los servicios de salud. En este contexto, la reorganización de la agenda de los profesionales es central en el sentido de garantizar la acogida y la continuidad del cuidado. Objetivo: Describir la prevalencia de absentismo a partir de la agenda de atención médica de un servicio de Atención Primaria a la Salud (APS) de enseñanza de graduación y postgrado del municipio de Pelotas, en el estado de Rio Grande do Sul (RS). Métodos: Se realizó un estudio transversal con la totalidad de la planificación de un mes de atención de cada estación del año, entre julio de 2016 y abril de 2017. Los datos fueron recolectados de la agenda física local, digitados y analizados en hoja de cálculo Excel®. Resultados: De 3.131 consultas médicas programadas fueron computadas 598 faltas, resultando en una prevalencia de absentismo del 19,2% (IC95% 17,7-20,8). De los 153 turnos de atención en apenas 2% no ocurrieron ausencias y, entre los demás, la prevalencia varió del 4,2% al 45%. En la distribución del absentismo entre los siete grupos de consultas encuestadas se destacaron el 62,3% de absentismo para las atenciones de clínica general y el 12,2% para la realización de examen citopatológico del cuello del útero. Conclusión: Los resultados muestran una elevada prevalencia de absentismo, especialmente en las consultas de clínica médica, lo que puede acarrear problemas tanto para la continuidad del cuidado, especialmente a los usuarios de la clínica general, como a la enseñanza médica en la APS. Este hallazgo es superior al encontrado por Tristão et al. en un estudio brasileño en servicios de salud de ambulatorios, e inferior al resultado descrito por Izecksohn y Ferreira en un Centro de Salud Escuela. Los autores sugieren la necesidad de cambios organizacionales en la oferta de consultas con el objetivo de ampliar el acceso y facilitar la adhesión a las consultas programadas, para garantizar la longitudinalidad del cuidado.

Health education and promotion actions among teams of the National Primary Care Access and Quality Improvement Program, Rio Grande do Sul state, Brazil. / Ações educativas e de promoção da saúde em equipes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, Rio Grande do Sul, Brasil.

OBJETIVO: to investigate the provision of health education and promotion actions in primary care, and their association with demographic characteristics and Family Health Strategy (FHS) coverage in Rio Grande do Sul state, Brazil. METHODS: this is a cross-sectional study conducted with 816 teams that adhered to the 2012 Primary Care Access and Quality Improvement Program. RESULTS: the most frequent actions were directed towards people with diabetes (91.2%), hypertension (90.8%) as well as antenatal and postnatal care (84.6%). The least frequent were directed to wards crack, alcohol and other drug users (32.4%), anxiolytic/benzodiazepine users (20.3%), people with tuberculosis (31.4%) and leprosy (21.0%). The greatest provision of health promotion and education actions occurred in smaller municipalities and with greater Family Health coverage. CONCLUSION: actions aimed at the reproductive period and chronic morbidities were the focus of primary care. FHS implementation strengthens health promotion.

Ações educativas e de promoção da saúde em equipes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, Rio Grande do Sul, Brasil / Acciones educativas y de promoción de la salud en equipos del Programa Nacional de Mejoría del Acceso y Calidad de la Atención Básica, Rio Grande do Sul, Brasil / Health education and promotion actions among teams of the National Primary Care Access and Quality Improvement Program, Rio Grande do Sul state, Brazil

Objetivo: investigar a oferta de ações educativas e de promoção da saúde na atenção básica e sua associação com fatores demográficos e cobertura da Estratégia Saúde da Família (ESF), no estado do Rio Grande do Sul, Brasil. Métodos: estudo transversal realizado com 816 equipes que aderiram ao Programa de Melhoria do Acesso e da Qualidade da Atenção Básica, 2012. Resultados: as ações mais frequentes eram direcionadas aos diabéticos (91,2%), hipertensos (90,8%) e ao pré-natal e puerpério (84,6%). As menos frequentes, aos dependentes de crack, álcool e outras drogas (32,4%), ansiolíticos e benzodiazepínicos (20,3%), assim como aos portadores de tuberculose (31,4%) e hanseníase (21,0%). As maiores ofertas de ações educativas e de promoção da saúde ocorreram nos municípios de menor porte e com maior cobertura de saúde da família. Conclusão: ações voltadas ao período reprodutivo e a morbidades crônicas eram o foco da atenção básica. A implementação da ESF fortalece a promoção da saúde.

Objetivo: investigar la oferta de acciones educativas y promoción de la salud en la atención básica y su asociación con factores demográficos y la cobertura de la estrategia de salud de la familia, en Rio Grande do Sul, Brasil. Métodos: estudio transversal con 816 equipos que adhirieron al Programa de Mejora del Acceso y Calidad en la atención básica, 2012. Resultados: las acciones más frecuentes eran dirigidas a diabéticos (91,2%), hipertensos (90,8%), prenatal y puerperio (84,6%). Las menos frecuentes, dependientes de crack, alcohol, otras drogas (32,4%), ansiolíticos/benzodiazepinas (20,3%), portadores de tuberculosis (31,4%) y lepra (21,0%). La mayor oferta de acciones educativas y de promoción ocurrió en municipios de menor porte y con mayor cobertura de salud de la familia. Conclusión: acciones dirigidas al período reproductivo y morbilidades crónicas eran el foco de la atención básica. La implementación de la estrategia de salud de la familia fortalece la promoción de la salud.

Objetivo: to investigate the provision of health education and promotion actions in primary care, and their association with demographic characteristics and Family Health Strategy (FHS) coverage in Rio Grande do Sul state, Brazil. Methods: this is a cross-sectional study conducted with 816 teams that adhered to the 2012 Primary Care Access and Quality Improvement Program. Results: the most frequent actions were directed towards people with diabetes (91.2%), hypertension (90.8%) as well as antenatal and postnatal care (84.6%). The least frequent were directed to wards crack, alcohol and other drug users (32.4%), anxiolytic/benzodiazepine users (20.3%), people with tuberculosis (31.4%) and leprosy (21.0%). The greatest provision of health promotion and education actions occurred in smaller municipalities and with greater Family Health coverage. Conclusion: actions aimed at the reproductive period and chronic morbidities were the focus of primary care. FHS implementation strengthens health promotion.

Hospitalizations for primary care-sensitive conditions in Pelotas, Brazil: 1998 to 2012. / Hospitalizações por condições sensíveis à atenção primária em Pelotas: 1998 a 2012.

OBJECTIVE:: To verify the hospitalization trend for primary care sensitive-conditions in Pelotas, Rio Grande do Sul, Brazil from 1998 to 2012. METHODS:: An ecological study compared hospitalizations rates of the city of Pelotas with the rest of state of Rio Grande do Sul. Analysis was conducted using direct standardization of rates, coefficients were stratified by sex and the Poisson regression was used. RESULTS:: Hospitalizations for sensitive conditions decreased in Pelotas and Rio Grande do Sul. In Pelotas, a 63.8% decrease was detected in the period observed, and there was a 43.1% decrease in the state of Rio Grande do Sul. Poisson regression coefficients showed a decrease of 7% in Pelotas and of 4% in the rest of Rio Grande do Sul each year. CONCLUSION:: During the study period, several changes were introduced in the Brazilian Unified Health System ("Sistema Único de Saúde") that may have influenced the results, including changes in administration, health funding, and a complete reworking of primary care through the creation of the Family Health Strategy program ("Estratégia Saúde da Família").

Hospitalizações por condições sensíveis à atenção primária em Pelotas: 1998 a 2012 / Hospitalizations for primary care-sensitive conditions in Pelotas, Brazil: 1998 to 2012

RESUMO: Objetivo: Verificar a tendência das taxas de internações por condições sensíveis à atenção primária no município de Pelotas, Rio Grande do Sul, de 1998 a 2012. Métodos: Foi realizado estudo ecológico comparando as taxas de Pelotas com as do restante do estado do Rio Grande do Sul. Na análise, fez-se padronização direta das taxas, os coeficientes foram estratificados por sexo e utilizou-se regressão de Poisson. Resultados: As internações por condições sensíveis diminuíram em Pelotas e no Rio Grande do Sul. Em Pelotas a redução das taxas no período foi de 63,8%, e no restante do Rio Grande do Sul, de 43,1%. Os coeficientes da regressão de Poisson mostraram diminuição de 7% no município de Pelotas e de 4% nas outras partes do Rio Grande do Sul por ano. Conclusão: Durante o período estudado, diversas alterações foram introduzidas no Sistema Único de Saúde (SUS), as quais podem ter contribuído para os resultados encontrados, como modificações na modalidade de gestão, nas formas de financiamento em saúde e na reestruturação da atenção primária mediante a consolidação da Estratégia Saúde da Família.

ABSTRACT: Objective: To verify the hospitalization trend for primary care sensitive-conditions in Pelotas, Rio Grande do Sul, Brazil from 1998 to 2012. Methods: An ecological study compared hospitalizations rates of the city of Pelotas with the rest of state of Rio Grande do Sul. Analysis was conducted using direct standardization of rates, coefficients were stratified by sex and the Poisson regression was used. Results: Hospitalizations for sensitive conditions decreased in Pelotas and Rio Grande do Sul. In Pelotas, a 63.8% decrease was detected in the period observed, and there was a 43.1% decrease in the state of Rio Grande do Sul. Poisson regression coefficients showed a decrease of 7% in Pelotas and of 4% in the rest of Rio Grande do Sul each year. Conclusion: During the study period, several changes were introduced in the Brazilian Unified Health System ("Sistema Único de Saúde") that may have influenced the results, including changes in administration, health funding, and a complete reworking of primary care through the creation of the Family Health Strategy program ("Estratégia Saúde da Família").

[Quality of prenatal services in primary healthcare in Brazil: indicators and social inequalities]. / Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais.

The aim of this study was to describe quality indicators for prenatal care in Brazil as part of the Program for the Improvement of Access and Quality (PMAQ-AB). The study analyzed number of prenatal visits, vaccination status, prescription of ferrous sulfate, physical examination, orientation, and laboratory tests, based on which a summary quality indicator was constructed. Data were collected in 2012-2013 during interviews conducted by External Evaluators of the PMAQ-AB, with 6,125 users who had done their last prenatal follow-up in Family Health units. During prenatal follow-up, 89% reported six or more visits, more than 95% received a tetanus booster and prescription of ferrous sulfate, 24% reported having received all the procedures in the physical examination, 60% received all the orientation, and 69% had all the recommended laboratory tests. Only 15% of interviewees had received adequate prenatal care, including all the recommended measures, and there was a significantly higher proportion of "complete" care in pregnant women that were older, with higher income, in the Southeast region of Brazil, in municipalities with more than 300,000 inhabitants, and in those with (HDI) in the upper quartile. There are persist social and individual inequalities that can be targeted by measures to upgrade the teams' work processes.

Diabetes Care in Brazil: Program to Improve Primary Care Access and Quality-PMAQ.

This article describes the primary health care offered to 8118 service users with diabetes in Brazil based on data from the PMAQ (Program to Improve Primary Care Access and Quality) first survey. Structure, access, service organization and management, and clinical care quality were analyzed. Prevalence of self-reported receipt of appropriate treatment was 14.3% (95% confidence interval [CI]: 13.4-15.2). Following adjustment, it was 26% higher (prevalence ratio [PR] = 1.26; 95% CI: 1.04-1.54) when primary health care centers had all the structure items investigated, it was 13% higher (PR = 1.13; 95% CI: 1.00-1.29) when the teams' work process for service organization and management was adequate and it was 14% higher (PR = 1.14; 95% CI: 1.00-1.30) when the teams' clinical practice was adequate.

Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais / Quality of prenatal services in primary healthcare in Brazil: indicators and social inequalities / Calidad de la atención prenatal en la red básica de salud de Brasil: indicadores y desigualdades sociales

O objetivo foi descrever indicadores de qualidade da atenção pré-natal no Brasil no âmbito do Programa de Melhoria do Acesso e da Qualidade (PMAQ-AB). Foram analisados número de consultas, situação vacinal, prescrição de sulfato ferroso, exame físico, orientações e exames complementares, com base no que se construiu como um indicador sintético de qualidade. Os dados foram coletados em 2012/2013 por meio de entrevistas realizadas por Avaliadores Externos do PMAQ-AB às 6.125 usuárias que fizeram seu último pré-natal nas unidades de saúde da família. Durante o pré-natal, 89% fizeram seis ou mais consultas, mais de 95% atualizaram a vacina antitetânica e receberam prescrição de sulfato ferroso, 24% referiram ter recebido todos os procedimentos de exame físico, 60% receberam todas as orientações e 69% realizaram todos os exames complementares. Apenas 15% das entrevistadas receberam atenção pré-natal adequada, considerando-se todas as ações preconizadas, sendo significativamente maior a proporção de completude da atenção em gestantes com mais idade, de maior renda, na Região Sudeste, nos municípios com mais de 300 mil habitantes e com IDH no quartil superior. Persistem desigualdades sociais e individuais que podem ser objeto de ações de qualificação dos processos de trabalho das equipes.

The aim of this study was to describe quality indicators for prenatal care in Brazil as part of the Program for the Improvement of Access and Quality (PMAQ-AB). The study analyzed number of prenatal visits, vaccination status, prescription of ferrous sulfate, physical examination, orientation, and laboratory tests, based on which a summary quality indicator was constructed. Data were collected in 2012-2013 during interviews conducted by External Evaluators of the PMAQ-AB, with 6,125 users who had done their last prenatal follow-up in Family Health units. During prenatal follow-up, 89% reported six or more visits, more than 95% received a tetanus booster and prescription of ferrous sulfate, 24% reported having received all the procedures in the physical examination, 60% received all the orientation, and 69% had all the recommended laboratory tests. Only 15% of interviewees had received adequate prenatal care, including all the recommended measures, and there was a significantly higher proportion of "complete" care in pregnant women that were older, with higher income, in the Southeast region of Brazil, in municipalities with more than 300,000 inhabitants, and in those with (HDI) in the upper quartile. There are persist social and individual inequalities that can be targeted by measures to upgrade the teams' work processes.

El objetivo fue describir indicadores de calidad de la atención prenatal en Brasil en el ámbito del Programa de Mejoría del Acceso y de la Calidad (PMAQ-AB). Se analizaron el número de consultas, situación de vacunación, prescripción de sulfato ferroso, examen físico, orientaciones y exámenes complementarios, en base a lo que se construyó como un indicador sintético de calidad. Los datos fueron recogidos en 2012/2013, mediante entrevistas realizadas por evaluadores externos del PMAQ-AB, entre 6.125 usuarias que realizaron su último examen prenatal en las unidades de Salud de la Familia. Durante el periodo prenatal, un 89% realizaron seis o más consultas, más de un 95% actualizaron la vacuna antitetánica y obtuvieron recetas de sulfato ferroso, un 24% informaron haber recibido todos los procedimientos de examen físico, un 60% recibieron todas las orientaciones y un 69% realizaron todos los exámenes complementarios. Solamente un 15% de las entrevistadas recibieron atención prenatal adecuada, considerándose todas las acciones preconizadas, siendo significativamente mayor la proporción "de en su totalidad" en la atención en gestantes con más edad, de mayor renta, en la Región Sudeste, en los municipios con más de 300 mil habitantes y con IDH en el cuartil superior. Persisten desigualdades sociales e individuales que pueden ser objeto de acciones de cualificación de los procesos de trabajo de equipos de salud.

[Access to medicines prescribed for acute health conditions in adults in South and Northeast Brazil]. / Acesso a medicamentos para tratamento de condições agudas prescritos a adultos nas regiões Sul e Nordeste do Brasil.

This was a cross-sectional study within Brazil's Project for the Expansion and Consolidation of Family Health, 2005, with the objective of universal and free access to the medication prescribed in the last medical appointment for acute health problems and to estimate the degree to which access may have improved with inclusion of the medicines in prevailing policies and programs. The sample included 4,060 adults living in the area of primary health care units in 41 municipalities in South and Northeast Brazil. Access was greater in the South (83.2%) than in the Northeast (71%), and free access was similar (37%), with a greater share by the Family Health Program (FHP) when compared to the traditional model, especially in the Northeast. Some 60% of prescribed medicines and 50% of those on the National List of Essential Medicines (RENAME) were paid for. No variation was observed in the proportion of medicines present on the prevailing RENAME list and access. However, 40% of the medicines that were paid for can currently be obtained through the Popular Pharmacy Program. The latter program appears to emerge as a new way to guarantee access to medicines prescribed in the health system.

Acesso a medicamentos para tratamento de condições agudas prescritos a adultos nas regiões Sul e Nordeste do Brasil / Access to medicines prescribed for acute health conditions in adults in South and Northeast Brazil / Acceso a medicamentos prescritos para adultos en el tratamiento de enfermedades graves en las regiones sur y nordeste de Brasil

Estudo transversal no âmbito do Projeto de Expansão e Consolidação Saúde da Família de 2005, com o objetivo de avaliar o acesso total e gratuito a medicamentos prescritos na última consulta médica, para problemas agudos de saúde, e estimar quanto o acesso pode ter melhorado com a inclusão dos medicamentos em políticas e programas vigentes. A amostra incluiu 4.060 adultos residentes na área das unidades básicas de saúde de 41 municípios do Sul e Nordeste do Brasil. O acesso foi maior no Sul (83,2%) do que no Nordeste (71%) e o acesso gratuito foi semelhante (37%), com maior participação do Programa Saúde da Família (PSF) em relação ao modelo tradicional especialmente no Nordeste. Cerca de 60% dos medicamentos prescritos e 50% dos presentes na Relação Nacional de Medicamentos Essenciais (RENAME) foram pagos. Nenhuma variação foi observada na proporção de medicamentos presentes na RENAME vigente e acesso. Contudo, 40% dos medicamentos que foram pagos podem atualmente ser obtidos por meio do Programa Farmácia Popular. Esse programa parece surgir como uma nova forma de garantir o acesso a medicamentos prescritos no sistema de saúde.

This was a cross-sectional study within Brazil's Project for the Expansion and Consolidation of Family Health, 2005, with the objective of universal and free access to the medication prescribed in the last medical appointment for acute health problems and to estimate the degree to which access may have improved with inclusion of the medicines in prevailing policies and programs. The sample included 4,060 adults living in the area of primary health care units in 41 municipalities in South and Northeast Brazil. Access was greater in the South (83.2%) than in the Northeast (71%), and free access was similar (37%), with a greater share by the Family Health Program (FHP) when compared to the traditional model, especially in the Northeast. Some 60% of prescribed medicines and 50% of those on the National List of Essential Medicines (RENAME) were paid for. No variation was observed in the proportion of medicines present on the prevailing RENAME list and access. However, 40% of the medicines that were paid for can currently be obtained through the Popular Pharmacy Program. The latter program appears to emerge as a new way to guarantee access to medicines prescribed in the health system.

Estudio transversal en el ámbito del Proyecto de Expansión y Consolidación Salud de la Familia de 2005, con el objetivo de evaluar el acceso total y gratuito a medicamentos prescritos en la última consulta médica, para problemas graves de salud, y estimar la mejora en su acceso con la inclusión de los mismos en las políticas y programas vigentes. La muestra incluyó a 4.060 adultos, residentes en el área de las unidades básicas de salud de 41 municipios del Sur y Nordeste de Brasil. el acceso fue mayor en el Sur (83,2%) que en el Nordeste (71%) y el acceso gratuito fue semejante (37%) con una mayor participación del Programa Salud de la Familia (PSF), en relación con el modelo tradicional, especialmente en el Nordeste. Cerca de un 60% de los medicamentos prescritos y un 50% de los presentes en la Relación Nacional de Medicamentos Esenciales (RENAME) fueron pagados. No se observó ninguna variación en la proporción de medicamentos presentes en la RENAME vigentes y en acceso. No obstante, un 40% de los medicamentos que fueron pagados pueden ser actualmente obtenidos mediante el Programa Farmacia Popular. Este programa parece surgir como una nueva forma de garantizar el acceso a medicamentos prescritos en el sistema de salud.

Lack of access and continuity of adult health care: a national population-based survey.

OBJECTIVE To describe the lack of access and continuity of health care in adults. METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas. RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care. CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Estrutura e processo de trabalho na prevenção do câncer de colo de útero na Atenção Básica à Saúde no Brasil: Programa de Melhoria do Acesso e da Qualidade – PMAQ / Structure and work process in the prevention of cervical cancer in Health Basic Attention in Brazil: Program for the Improvement of Access and Quality

Descrever e analisar a adequação da estrutura e processo das equipes do Programa de Melhoria do Acesso e da Qualidade (PMAQ-AB) na prevenção do câncer de colo de útero na Atenção Básica no Brasil. Métodos: estudo transversal conduzido em todas as unidades básicas de saúde (UBS), entre 2012 e 2013. Estimou-se a prevalência da adequação da estrutura (insumos/materiais) e do processo de trabalho para o exame de Papanicolau. A associação da adequação com características das unidades e equipes foi estimada pela razão de prevalência (RP) e intervalos de confiança de 95 por cento (IC95 por cento). Resultados: foram estudadas 38.812 UBS e 17.202 equipes de saúde. A prevalência de adequação da estrutura e do processo de trabalho foi 49 por cento e 30 por cento, respectivamente. A adequação da estrutura e o processo estiveram associados ao maior porte do município e IDH. A prevalência de adequação da estrutura foi maior nas unidades da Estratégia de Saúde da Família (RP=1,35; IC95 por cento:1,33-1,38), cuja adequação do processo de trabalho esteve associada à população adscrita <4.000 pessoas e equipe mínima completa. Conclusões: a estrutura e o processo de trabalho para o rastreamento do câncer de colo uterino necessitam ser aprimoradas. As equipes de saúde carecem de maior qualificação das ações relacionadas a esta ação programática...

To outline and examine the adequacy of the structure and processes used by Access and Quality Improvement Program (PMAQ-AB) teams to prevent cervical cancer during basic care in Brazil. Methods: a cross-sectional study was carried out at all basic health units (BHUs), between 2012 and 2013. The prevalence of adequate structure (infrastructure and materials) and working processes for conducting the Pap test was calculated. The association of adequacy with characteristics of the units and their teams were measured using the prevalence ratio (PR) and confidence intervals of 95 percent (CI95 percent). Results: 38,812 BHUs and 17,202 healthcare teams were studied. The prevalence of adequate structure and working processes was 49 percent and 30 percent, respectively. The adequacy of structure and processes was associated positively with largely size of municipality and higher HDI. The prevalence of adequate structure was higher at units adopting the Family Health Strategy (PR=1.35; CI95 percent: 1.33-1.38) and the adequacy of their working processes was associated with having a registered population of <4,000 individuals and full minimal team. Conclusions: the structure and processes used to screen for cervical cancer need to be improved. Healthcare teams need to provide better quality intervention in relation to this program...

Perfil de utilização de serviços de saúde por crianças de zona urbana no Brasil: estudo transversal de base nacional / The pattern of use of health services by children from urban areas in Brazil: a cross-sectional national study

Descrever o perfil de utilização de serviços de saúde em crianças brasileiras menores de cinco anos. Métodos: estudo seccional de base populacional realizado em 2009, com crianças residentes em 100 municípios de cinco regiões brasileiras. Investigou-se o uso dos seguintes tipos de atendimento de saúde: domiciliar e médico ambulatorial - últimos três meses - e de urgência e internação hospitalar - últimos doze meses. As variáveis independentes foram: sexo, idade, classificação econômica familiar, escolaridade materna, família beneficiada pelo Programa Bolsa Família, ter apresentado problema agudo de saúde, estado nutricional, porte do município e região. Análises brutas e ajustadas para associação entre a utilização de serviços de saúde e classe econômica foram realizadas por meio de regressão de Poisson com ajuste robusto da variância. Resultados: das 6360 crianças, 3422 (54 por cento) foram atendidas por médico, 506 (8 por cento) receberam atendimento domiciliar, 2144 (34 por cento) foram atendidas em serviços de urgência/emergência e 681 (11 por cento) foram hospitalizadas. Crianças das classes A/B consultaram mais com o médico, tiveram menos atendimento domiciliar, usaram mais serviços de urgência do que crianças das classes C e D/E. Não houve diferença na hospitalização segundo classe econômica. Conclusões: os achados destacam importantes desigualdades no uso de serviços de saúde por crianças brasileiras...

To describe the pattern of use of health services by Brazilian children aged under five years. Methods: a population-based cross-sectional study was conducted in 2009 with children from 100 municipalities across five regions of Brazil. Use of the following types of health care was investigated: house-calls and outpatients doctor - previous three months - and emergency services and admission to hospital – previous twelve months. The independent variables were: sex, age, household income, level of schooling of mother, family receiving Family Grant Program benefits, having had an acute health problem, nutritional status, size of municipality, and region. Raw analyses and analyses adjusted for the association between the use of health services and economic status were carried out using Poisson's regression as a robust adjustment of variance. Results: of the 6,360 children, 3,422 (54 percent) were attended by a physician, 506 (8 percent) received a housecall, 2,144 (34 percent) were attended by emergency services and 681 (11 percent) were hospitalized. Children from socioeconomic class A/B consulted a doctor more, received fewer house-calls, and used the emergency services more than children from classes C and D/E. There was no difference in the frequency of admission to hospital according to socioeconomic status. Conclusions: the findings point to significant inequalities in the use of health services by Brazilian children...

Adult Physical Activity Counseling by Health Professionals in Brazil: A National Urban Population Survey.

BACKGROUND: Physical activity counseling is an attribution of health professionals. As such, this paper aims to analyze the receipt of this form of counseling. METHODS: Cross-sectional national study interviewing 12,402 adults living in the urban area of 100 Brazilian municipalities. RESULTS: Overall counseling prevalence was 30%, falling to 20% when considering only counseling provided by health professionals. Counseling was significantly more frequent among women and among individuals who were older, married, had higher socioeconomic status, were former smokers, physically active, and reporting hypertension, diabetes, and excess weight. CONCLUSIONS: Little counseling was found to be done, this being a missed opportunity for health promotion. Health services and professionals therefore need to be trained and encouraged to provide adequate information to all health service users on the benefits of leading healthy lifestyles.