Evaluation of the performance of tuberculosis control actions and services of the family health strategies

Fábia Maria de Santana^{I, II}; Ana Paula de Araújo Machado^III; Patrícia Poleto Monhol^III; Ligia Ajaime Azzalis^IV; Virginia B. C. Junqueira^IV; David Feder^IV; Leela Morená^V; Fernando Luiz Affonso Fonseca^{II, IV}

^ISanitary Physiotherapist by the School of Government in Public Health of the State of Pernambuco, Master's Degree in Health Sciences by ABC Medical School, Santo André, SP, Brazil
^IICommission for Postgraduate, Research and Innovation. Postgraduate Program in Health Sciences. Faculty of Medicine of ABC, Santo André, SP, Brazil
^IIISchool of Sciences of Santa Casa de Misericórdia de Vitória (EMESCAM), Laboratory of Scientific Writing - Nursing
^IVDepartment of Pharmaceutical Sciences, Federal University of São Paulo, UNIFESP, Diadema, SP. Laboratory of Clinical Analysis, ABC Medical School, Santo André, SP, Brazil ]]> ^VFederal University of the Valley of the São Francisco - Collegiate of Medicine, Petrolina, Pe, Brazil. Laboratory of Study Design and Scientific Writing, ABC Medical School, Santo André, SP, Brazil

ABSTRACT

INTRODUCTION: Front of the persistence of tuberculosis in several municipalities in the country, the Ministry of Health (MS) established the National Tuberculosis Control Plan (NTCP), whose goals were to integrate 100% of the Brazilian municipalities in the fight against the disease.
OBJECTIVE: To evaluate the performance of tuberculosis (TB) control actions and services of the Family Health Strategies in the city of Salgueiro-PE.
METHOD: Cross-sectional, quantitative and descriptive survey study that evaluated health services in the city of Salgueiro-Pe, involving 40 participants. The data were selected through the steps of specific questions for the evaluation of TB, in addition to the questions on the epidemiological situation and the current state of health. In order to know the conditions for the control of TB in the municipality, a script was also elaborated with orientations directed to the manager.
RESULTS: The results of our study showed a population aged from 34 to 59 years with a predominance of males (70%) and incomplete elementary school (37.5%). Regarding the place of diagnosis, the hospital had a higher prevalence of cases diagnosed with tuberculosis with 62.5%. 85,0% performed the Directly Observed Treatment. The averages of the evaluated actions showed that the municipality of Salgueiro-PE does not develop actions of health education and active search of symptomatic respiratory patients, The results were favorable only for the accomplishment of sputum bacilloscopy, monthly consultations of control and medical monitoring.
CONCLUSION: The results showed weaknesses in the performance of actions and services by the Family Health Strategy in the municipality of Salgueiro, with damage to TB control and treatment.

Keywords: Tuberculosis, primary health care, evaluation of health services.

INTRODUCTION

Basic care is the result of the development and consolidation of the Health Unic System (HUS) through the Family Health Strategy (FHS) program. Created in 1994, the FHS covered 63% of the Brazilian population in 2015 and has been associated with the reduction in infant mortality and the number of preventable hospitalizations¹. Basic care is the result of the development and consolidation of Unified Health System (UHS) through the Family Health Strategy (FHS) program. A study conducted in Belo-Horizonte-MG with a sample of 7,778 adults, showed that individuals attended by the FHT had a better performance in health usage when compared to non-SUS users. In this context, the Family Health Strategy has been an important tool in the management of diseases prevalent in national epidemiology, such as tuberculosis (TB)².

TB is an infectious disease, considered a public health problem, punctuating with high magnitude, transcendence and vulnerability in the criteria for disease selection and priority aggravations to epidemiological surveillance³.

In 1993, the WHO declared a state of emergency against TB. As a reflection, Brazil developed strategies within the FHS signaling its position through the creation of the Emergency Plan for Tuberculosis Control, the first strategy of the Ministry of Health in the fight against tuberculosis⁴. In a short time another strategy was defined, the National Policy for the Control of Tuberculosis (NPCT), resulting from the need to increase considerations about the tuberculosis problem, with a view to making interventions in the health system in Brazil and on the possible contributions that the incorporation of new technologies may lead to on the disease surveillance system⁵.

The NPCT understands TB treatment as a responsibility of all HUS services and recognizes the need to integrate basic care, including programs of community agents and family health, aiming at greater access to the management of this disease. Therefore, basic care is structured as the first point of attention and the main entry point of the system, consisting of a multidisciplinary team that covers the entire population, integrating, coordinating care and attending to their health needs. Decree No. 7,508, of July 28, 2011, which is regulated by Law No. 8,080 / 90, defines that "universal, equal and orderly access to health actions and services starts at the entrance door of the HUS and it is completed in the regionalized and hierarchical network"⁶.

Among the activities performed by primary care, besides the diagnosis and treatment of TB are: active search for respiratory symptoms (people with cough and expectoration for more than 3 weeks), supervising the control of contacts of patients with bacilli in the community, notifying the Information System called SINAN, follow-up of the cases under treatment, ensuring the performance of the diagnostic tests, participating in the operationalization of the treatment directly observed in the municipality, and following the prophylactic control measures⁷.

The definition of TB as a priority in the public health agenda at local level runs through operational and political obstacles, such as the distribution of resources prioritizing other situations such as urgency / emergency and dengue care. There is a gap in the financing policy for TB and a municipal management pattern that is not very committed to disease control, and the manager's involvement in incorporating, investing and supporting the management of TB control actions is fundamental, assuming the disease as a priority in the municipal health agenda⁸.

Thus, the purpose of this manuscript is to analyze the performance of tuberculosis control actions and services of the Family Health Strategy.

METHODS

Type of study

Descriptive survey study for the evaluation of health services, of a quantitative nature and cross-sectional character.

Sample selection process

The research used the structure of the 18 Family Health Strategies (FHS) of the municipality of Salgueiro-PE to locate the addresses of TB patients. Data were collected at the homes of each patient who had or was still under TB treatment, through the participant researcher with the community health agents (CHA). During the collection period, some elements were facilitators and others obstacles to this process (Table 1).

The study followed the principles normalized by the National Health Council (CNS), by resolution n. 466, December 2012, taking into consideration the ethical aspects that regulate the research involving human beings

Participants

To select the sample of the research, an analysis was carried out together with the epidemiological surveillance to identify the number of cases described in the registry book and follow-up of the treatment of patients with tuberculosis from January 2014 to September 2016. A population of 84 TB patients enrolled in the family health strategy was obtained. The following criteria were used as inclusion criterion: age 18 years or older, having good cognition, living in the city of Salgueiro / PE, who performed or performed the treatment at FHS and consent to the study by signing the FCCT. Exclusion Criteria: TB patients who are in the prison system.

Data collection instrument

The research data were collected through a questionnaire developed for TB patients from the Primary Care Assessment Tool⁹, validated and adapted for TB attention¹⁰. The instrument contains 86 specific questions for each essential organizational component of basic care for TB control actions, as well as questions on patient profile, clinical epidemiological information and current health status.

The Likert scale was used to evaluate the level of agreement in opinion polls. A value of 0 to 5 was assigned. "Zero" identified the "do not know or do not apply" response and values from 1 to 5 record the degree of preference (or agreement) relationship of the statements.

To better identify which policies exist in the municipality of Salgueiro-PE for TB control, an interview script was developed for the main actor (manager) involved in the reorganization process of health services.

Statistical analysis

Absolute and relative values were used to describe the characteristics of the qualitative variables for the quantitative variables, median and percentiles. A confidence level of 95% was used for all analyzes and the statistical program used was the Data Analysis and Statistical Software for Professionals (Stata) version 11.0®. After obtaining the averages, these were related to the Likert scale.

The main aspects and variables analyzed were:

●Regarding the sociodemographic character: Sex, age, and schooling

●Regarding health education: conducting health education on subjects other than TB, Participation of TB patients in groups in health services, Educational work carried out by health professionals in the community.

●Regarding medication control: Access to medical care if malaise due to medication, the absence of medication during treatment for TB

●Regarding the previous diagnosis and follow-up in the treatment of TB: Offer by the health services of the recipients for monthly sputum examination; Visit of health professionals to deliver the recipients for sputum collection; Actions with churches, neighborhood associations, for delivery of the recipients for sputum collection; Performing the skin test by the health services; Monthly consultation offered by health services.

RESULTS

Of the 84 registered cases of tuberculosis, 16 (19%) of the patients moved to another municipality, 49 (58%) with discharge for cure, 5 (6%) in the prison system, 3 (4%) with changes on diagnosis, 2 (2%) TB with associated diseases such as pneumonia and pleural effusion, 1 (1%) TB + HIV, 5 (6%) deaths and 3 (4%) wanderers (without fixed residence). Thus, the sample studied consisted of 40 patients. Figure 1, below, presents the process of locating tuberculosis cases (Figure 1).

DISCUSSION

The incidence rate of TB in Brazil is high^12,13. In 2013, Brazil registered 71,123 new cases of tuberculosis, equivalent to an incidence rate of 35.4 cases per 100,000 inhabitant which indicates a decrease of 20.3% in relation to 2003 when the rate was 44.4 cases per 100 thousand people. Also, in 2013, 4,406 deaths per TB were reported at a rate of 23 deaths per 100,000 inhabitants. Brazil ranks the 16th place among the 22 countries with the highest TB prevalence and 111th in terms of incidence rates. According to the Ministry of Health, in 2011 were estimated 9 million new cases of the disease in the world, in addition to 1.4 million deaths^14,12.

In Pernambuco, there is an average of 4,230 new cases of tuberculosis per year. The State presented the 4th place in disease detection rate and 2nd place in mortality in the country and 1st place in number of cases in the Northeast in 2010, being Recife the Brazilian capital with the highest incidence rate (48.2%), and one of the municipalities that make up the I Regional Health Administration (I GERES), which holds 70% of tuberculosis cases among the 12 GERES of the state¹⁵.

In Brazil, the number of tuberculosis cases in males is twice the number of females, around 50 per 100,000 inhabitants¹¹. In this study, the socio-demographic characteristic revealed that of the 40 TB patients, there was a predominance of males with 70% (28), compacting with national information¹⁶. This trend may be related to the greater exposure of men outside the home and also because, culturally, men resort less to health services¹⁷.

The sociodemographic characterization of the eligible participate sample (40 patients) was predominantly male (70%), 30% (12) had incomplete primary education and 37.5% (15) were between the ages of 34 to 59 years of age (table 1).

When asked about the primary diagnosis site, the hospital environment had a higher prevalence of diagnosed cases with tuberculosis with 62.5% (25) versus 37.5% (15) of diagnoses within the FHS.

Participants were also questioned about directly observed treatment (DOT), a strategy established by the National Tuberculosis Control Program (NTCP) to regulate and enable the quality of TB patient care, with the primary action being the supervision of medication, made by a professional or person properly qualified for this purpose, and it should be performed in any environment, which is more comfortable for the user^11,10. The DOT helps reduce the possibility of drug resistance, withdrawal from treatment and encouraging adherence to therapy.

Among the TB patients interviewed, 85.0% (34) performed the DOT, with only 15.0% (6) who did not (Figure 2). Regarding the place of care, 27.5% (11) performed the supervised treatment at the FHS and 72.5% (29) at home.

The results found for the variables: "access to medical care within 24 hours when an incident caused by the use of medication happens", obtained a regular average indicating that the study patients commonly have access to the health service. The data collected on a Likert scale for "lack of medication" obtained an average of 100% for the "almost never" response, presenting a favorable level, that is, almost never missing medication (Table 3).

The mean reached in the four variables: "offer by the health services of the recipients for diagnosis of TB"; "Offer by the health services of the recipients for monthly sputum examination"; "Monthly consultation offered by health services"; "Visits by health professionals to deliver the recipients for sputum collection", in the services of the FHS were favorable, that is, the recipients were always offered for diagnosis and examination as well as monthly consultation of control and visit of health professionals were done.

However, the results were not favorable in the variables " skin test performed by the health services"; "Service actions with churches, neighborhood associations, for delivery of recipients for sputum collection", that is, these activities are never performed by FHS.

Sociodemographic Characterization

About schooling, the study showed a higher frequency among patients with incomplete primary education, 37.5% (15) of the sample. In a research performed in Rio de Janeiro, referring to the distribution of monthly consultations of tuberculosis according to demographic and clinical variables of the users, almost 40% corresponded to individuals without schooling or incomplete elementary education¹⁸.

According to Lindoso et al.¹⁹ and Santos et al.²⁰, people with low educational level have a lower adherence to TB treatment, because they have an erroneous perception of the disease and do not seek health services, regarding the diagnosis and treatment, and increasing the abandonment number^19,20.

The interviewees under study were within the economically active age group, between 34 to 59 years of age. These data corroborate with a study conducted by Ferrer et al.²¹. in Santa Catarina, where the highest rates found were in the age groups of 30-44 and 45-59 years and with a study carried out in the city of Teresina-PI. In this study, the incidence was between the age group older than 50 years^21,22.

Regarding the diagnosis site, the hospital had a higher prevalence of cases diagnosed with tuberculosis with 62.5%, as presented in surveys carried out by Silva Sobrinho23 and Ponters et al.²⁴ , where this reality reflects a reversal of the flow of treatment and diagnosis of tuberculosis, since primary health care is recommended as a preferential gateway to the HUS. Thus, its noted the difficulty of the basic network in identifying and meeting the needs of the community, which causes overcrowding of the emergency sector with problems that could be solved in other levels of attention^23,24.

Directly Observed Treatment

Discontinuation of therapy is one of the major obstacles to TB cure and it is considered a multifactorial problem. According to a study by Chirinos et al.²⁵, the sociodemographic factors are the ones that are most related to this abandonment, so it is recommended that this team has effective and vigilant control over drug therapy²⁶. For Souza et al.²⁶ .the greatest difficulties in TB control are the delay in seeking the health service due to the fear of diagnosis, as well as the fear of discrimination by society, therefore it is necessary that users are familiarized with the health team of FHS.

Among the TB patients interviewed, 85% performed supervised treatment and only 15% did not participate in the DOT. Regarding the place of care, 27.5% had supervised treatment at the FHS and 72.5% at home. Research carried out in several municipalities in the country shows that primary care effectively performs the DOT, but still can not reach a total of 100% of patients⁴.

Health education

The variables "health education activity on subjects besides TB", "TB patients participation in health services groups", obtained a non-favorable result, indicating that they did not perform any of these activities. However, the variable "Educational work carried out by health professionals in the community" obtained an average of 45% indicating a regular level. These data reveal the conception of the health-disease process is still very closely linked to the clinic itself, showing a discrepancy with what is proposed by the principles and guidelines of the HUS, which has health education as a basis for health promotion^27-30.

In addition, the study shows that the service evaluated does not develop health education actions in TB control, especially in the indicator "patient participation in groups", even though these actions are considered by the Ministry of Health and recommended in the NTCP as a primary strategy control and adherence to TB treatment.

Health education should be developed through organized and teamwork, being used as a strategy for TB control, developing patient empowerment, and promoting dialogue between health professionals and users, citizen autonomy and the encouragement of an active posture of these subjects in their political and social environments, developing opportunities to enlarge the understanding of the problems and to reflect on the intervention about the reality in which they live, privileging the promotion of their autonomy^{31, 32}.

Teamwork was codified by the group as the primary point for the performance of the family health strategy. During the decoding/problematization, the major contributions of the subjects were shown through the perspective that the common goal of care and health promotion of the population can only be achieved through teamwork.

A study by Sá et al.³¹ corroborates our findings, where health education practices are incipient and not very expressive in the work process of primary health care professionals²⁶.

One of the strategies considered a priority by the NTCP is predicted to increase case detection in different socioeconomic and clinical epidemiological scenarios by strengthening the primary health care (PHC) service system. It is extremely important that the family health team acts in the surveillance, prevention and control of the disease^33-35.

The results found in this study show that medical care within 24 hours was regular, indicating access to the health service. This aspect diminishes the incidence of treatment abandonment of tuberculosis since health professionals are accessible to guide, evaluate and monitor the health status of the TB carrier. According toSantos et al.²⁰ and Rodrigues et al.³⁴, the perception of the relations with the health service and the institutional field can be factors that contribute or not to the abandonment of the treatment, since the side effects presented by the patients can cause extra consultations to treat the complaints^20,35.

The data about "lack of medication" averaged 100%, presenting a favorable level, that is, never or almost never missing medication. The delivery of the medication is exclusive to the health services, as they can not be sold in pharmacies, and the misuse of medication is one of the risk factors for the patient to become resistant to the drug, because of this, the treatment can't be interrupted. The NTCP, when refers to TB control, is primarily aimed at breaking the chain of transmission and the main means to achieve this goal is to perform the diagnosis and early treatment so that bacilli are not disseminated, with the outcome of curing the disease^11,13.

A study conducted by Lafaiete et al.³⁵ indicate that the results are favorable with medical care within 24 hours, with access to drugs for the treatment of TB. This fact reveals an adequate planning and distribution of drugs by the team that coordinates the treatment control program in the municipality, as they include essential steps in the selection, procurement, distribution and appropriate use of the drug.

Diagnosis

Bacilloscopy is used in public health to confirm the diagnosis of TB since it is a simple and safe technique, it has two important purposes in TB control: detection of bacilliferous cases, responsible for the chain of transmission, and control of treatment and efficacy. For this reason, it is recommended that in all TB diagnoses a bacilloscopy for confirmation be requested and that it be performed every month, that the communicants and other citizens perform the skin test (PST), for an early diagnosis^11,36.

The follow-up of TB treatment was evaluated through periodic sputum controls in the variables: "offer by the health services of the recipients to diagnose TB"; "Offer by recipients health services for monthly sputum examination"; "Monthly consultation offered by health services"; "Visits by health professionals to deliver the recipients for sputum collection". The results showed that such monitoring has been a priority in the city of Salgueiro, presenting favorable percentage levels (table 4). Corroborating with a study carried out by Lima et al.³⁷, who presented positive results regarding the performance of follow-up smear microscopy.

Control actions such as "perform the skin test by the health services" and "actions with churches, neighborhood associations, to deliver the recipient for sputum collection", have had unfavorable results, which determines that the municipality has not met all the goals of the NTCP, which has only been conducting clinical actions, and regarding promotion and prevention actions, such as active search and exams for early diagnosis, such as PST, has not performed them in the municipality under study . These data are corroborated with studies carried out by Oliveira³⁸ in Ribeirão Preto - SP, showing the same profile where the diagnostic bacilloscopy is performed, but the active search is not done.

The supply of recipients for sputum examination in the community and the PST, has been the priority action in the active search for respiratory symptoms, becoming part of the routine of services and mainly primary health care, in order to obtain the early detection of cases of TB. Having as an instrument of work the family and the home, the FHS has a privileged space for these actions^39,40.

Repercussions in the Field of Public Health

In this way, it is important to highlight the study conducted by Queiroz et al.⁴² and Terra et al.⁴³ on the identification of problems related to therapeutic adherence and TB control, in which they highlighted that issues related to the qualification of the teams need to reach a greater discussion and execution, since most of the professionals who work in primary care have already experienced the training process centered on the curativist model and not on health promotion.

For Samico et al.⁴⁴,, health evaluation has become an effective alternative to provide answers regarding planned and executed actions, providing information on the way health systems users function, quality, effectiveness, safety and satisfaction. Thus, this study allowed the verification of actions, such as health education and the active search for respiratory symptomatic patients, which, even if it did not occur, the manager reported being executed. This leads to the generation of information that will give managers and health professionals the need to reflect and intervene in these indicators to modify the epidemiological picture presented by the disease, indicating the need for research and research that produce positive results in the disease process and improvement of the population's health^45,46.

It is observed that TB patients are mostly young adults with low schooling and males, which generates a social-economic problem for families, since the disease often leaves this group unable to work, taking from the provider the condition of livelihood.

Although the municipality has favorable conditions to carry out tuberculosis control actions in primary care, it is possible to detect a large concentration of diagnoses identified by the hospital's network, causing a reversal of the flow of care and diagnosis of tuberculosis. There was a satisfactory performance in relation to the activities related to the offer of treatment actions, such as medical care, bacilloscopy, and medications. As a result of the non-execution of some health indicators such as an active search for respiratory symptomatic and health education, TB control actions remain at a favorable, non-favorable and regular level, which determines that there is no linearity in TB control actions in the FHS.

Therefore, the findings of this study point to the need to implement policies aimed at health education and active search for respiratory symptomatic patients, with actions directed not only at the sick but also at the family and community levels. For this, the commitment of the management in the actions established in the control of TB in the municipality, as well as the health professionals and the population involved, must know its real assignments, in order to fulfill the goals suggested by the World Health Organization (WHO) and MH in the fight against the disease.

CONCLUSION

The evaluation of the performance of tuberculosis control actions and services of the family health strategy in the city of Salgueiro-PE pointed to weaknesses in the diagnosis of TB, as seen in the flow of care and diagnosis of tuberculosis, absence in the actions of health education and search active respiratory symptomatic, which end up causing damage to the control and treatment of tuberculosis.

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Manuscript received: April 2018
Manuscript accepted: October 2018 ]]> Version of record online: November 2018