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O desafio do conhecimento: pesquisa qualitativa em saúde

El objetivo fue describir indicadores de calidad de la atencion prenatal en Brasil en el ambito del Programa de Mejoria del Acceso y de la Calidad (PMAQ-AB). Se analizaron el numero de consultas, situacion de vacunacion, prescripcion de sulfato ferroso, examen fisico, orientaciones y examenes complementarios, en base a lo que se construyo como un indicador sintetico 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 ultimo examen prenatal en las unidades de Salud de la Familia. Durante el periodo prenatal, un 89% realizaron seis o mas consultas, mas de un 95% actualizaron la vacuna antitetanica y obtuvieron recetas de sulfato ferroso, un 24% informaron haber recibido todos los procedimientos de examen fisico, un 60% recibieron todas las orientaciones y un 69% realizaron todos los examenes complementarios. Solamente un 15% de las entrevistadas recibieron atencion prenatal adecuada, considerandose todas las acciones preconizadas, siendo significativamente mayor la proporcion "de en su totalidad" en la atencion en gestantes con mas edad, de mayor renta, en la Region Sudeste, en los municipios con mas de 300 mil habitantes y con IDH en el cuartil superior. Persisten desigualdades sociales e individuales que pueden ser objeto de acciones de cualificacion de los procesos de trabajo de equipos de salud.

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Calidad de la atención prenatal en la red básica de salud de Brasil: indicadores y desigualdades sociales

Background
Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.
This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

Objectives
To identify, appraise, and synthesise qualitative studies exploring:
·	Women’s views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women’s accounts;
·	Healthcare providers’ views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.
Search methods
To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched 
reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

Selection criteria
We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

Data collection and analysis
Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta- ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

Main results
We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high- confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or
moderate-confidence findings:
For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women’s need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women’s perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.
The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women’s belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

Authors' conclusions
This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Provision and uptake of routine antenatal services: a qualitative evidence synthesis

The National Health Promotion Policy reasserted the Brazilian Ministry of Health's commitment to bolster the promotion of health in the Unified Health System. In this context, the Health Academy Program constitutes a new tool of the health network for the enhancement of individual and collective primary healthcare. The scope of this study is to present the program implementation scenario, describing characteristics of its operation in the country. Data were collected through an electronic form sent to all Municipal Health Departments that received federal resources to implement the program. The response rate was 85%, corresponding to 2,418 municipalities. A total of 856 centers were found to be in operation, primarily promoting physical exercise, healthy eating and health education. The main participants were adults and the elderly. Difficulties reported by the administrators involve the inclusion of children and adolescents and the hiring of professionals. Over 90% of the program centers do not depend exclusively on federal funding for operation and receive municipal support to conduct their activities. The results show the potential of the program as a strategy to promote healthcare in the community nationwide in Brazil.

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O Programa Academia da Saúde como estratégia de promoção da saúde e modos de vida saudáveis: cenário nacional de implementação

Na adolescencia, a vivencia da sexualidade torna-se mais evidente. Muitas vezes, manifesta-se atraves de praticas sexuais inseguras, podendo se tornar um problema devido a falta de informacao, tabus ou mesmo pelo medo de assumi-la. O objetivo da pesquisa foi analisar o conhecimento dos adolescentes sobre sexualidade, metodos contraceptivos, gravidez, DST e aids, antes e apos oficinas de prevencao. Participaram 117 adolescentes da 8a serie de uma escola estadual de Londrina, Parana. Foi utilizado um questionario (pre e pos-teste) para identificar a diferenca do conhecimento dos adolescentes. Para a analise dos dados, usaram-se os testes quiquadrado e exato de Fischer. A faixa etaria concentrou-se entre 14 e 16 anos. Os meninos iniciaram mais cedo suas atividades sexuais. Apenas 28,2% dos adolescentes no pre-teste sabiam do periodo fertil da menina; apos as oficinas de prevencao, o conhecimento superou 55,8%. A aids foi a DST mais citada no pre-teste; no pos-teste, houve referencia a outras doencas (41,1%). Os metodos contraceptivos mais conhecidos sao o preservativo e a pilula. Nao houve relevância estatistica entre as respostas sobre atitudes de risco para transmissao de DST/aids. Conclui-se que ha necessidade de trabalho sistematico, a medio e longo prazo, sobre sexualidade na escola para os adolescentes.

/pdf/adolescents-knowledge-about-sexuality-before-and-after-37yhaq4kuo.pdf

Adolescents: knowledge about sexuality before and after participating in prevetion workshops

O artigo analisa resultados e limites de um projeto de extensao universitaria realizado em um servico publico de saude com atendimento integral ao adolescente. O projeto foi desenvolvido atraves de metodologia participativa, envolveu academicos e profissionais das areas de saude e humanas, respondendo a necessidade de se realizar trabalhos de prevencao com adolescentes. O projeto justifica-se pelo aumento dos indices de gravidez nao planejada entre meninas; pelos indices de infeccao de DST e Aids; e pelo uso de drogas. Programas de saude e o cumprimento dos conteudos dos Parâmetros Curriculares Nacionais do MEC poderiam atuar para minimizar a vulnerabilidade sociocultural de jovens. Oficinas de prevencao possibilitaram melhor interacao entre os profissionais do servico e os adolescentes, alem de representarem um espaco de reflexao sobre assuntos relacionados a sexualidade, temas dificilmente discutidos com a familia ou na escola. As oficinas apresentam-se, portanto, como instrumentos eficazes de prevencao e de promocao a saude, podendo ser operacionalizadas, nos servicos de saude, por equipes interdisciplinares.

https://www.scielo.br/pdf/csc/v8n2/a21v08n2.pdf

Oficinas de prevenção em um serviço de saúde para adolescentes: espaço de reflexão e de conhecimento compartilhado

This descriptive qualitative study was conducted in basic healthcare units to analyze the perceptions of physicians and nurses from family health teams concerning healthcare for adolescents, using content analysis with an emphasis on thematic analysis. The discourse of these health professionals showed that care exists for adolescents in the family health service, but that: it is not systematized because of other priorities; adolescents fail to use the service; the health professionals feel unprepared to draw adolescents to the service and treat them; and in order to implement a healthcare program for adolescents in the family health strategy it would be necessary to reorganize the service to train the existing team members and hire other professionals. Thus, the interviewees value differentiated care for adolescents, and even while recognizing their limitations and reporting not having been trained, they conduct joint actions with other areas beyond health, demonstrating that they transcend the limits of the health service and seek new ways of treating adolescents holistically.

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Healthcare for adolescents: perceptions by physicians and nurses in family health teams

/pdf/adolescencia-acciones-y-percepcion-de-los-medicos-y-3qqnycfv36.pdf

Adolescencia: acciones y percepción de los médicos y enfermeros del Programa Salud de la Familia

Objetivo: Avaliar a relacao entre assistencia pre-natal e orientacoes para o parto na Atencao Primaria a Saude. Metodos : Estudo transversal com 358 puerperas de maternidade publica do sul do Brasil. Coleta de dados realizada de julho a outubro de 2013, com transcricao de dados do cartao de pre-natal e entrevista estruturada. Dados analizados pelo Teste Qui-quadrado (p≤0,05). Resultados : O pre-natal teve alta cobertura (85,5%) e inicio precoce em 71,8% das mulheres, porem 52% destas nao receberam orientacao para o parto. Houve associacao estatistica entre o recebimento de orientacao para o parto e menor numero de consultas (p=0,028), maior intervalo entre a ultima consulta pre-natal e o parto (p=0,002) e classificacao do cuidado pre-natal como intermediario e inadequado (p=0,024). Conclusoes : Apesar da oferta ideal do numero de consultas, a qualidade do cuidado foi classificada como intermediaria ou inadequada e evidenciou-se acesso precario a orientacoes para o parto durante o pre-natal. Palavras-chave: Cuidado pre-natal. Parto. Educacao em saude. Enfermagem obstetrica.

/pdf/pre-natal-preparo-para-o-parto-na-atencao-primaria-a-saude-1x7d4nh0sh.pdf

Rosângela Aparecida Pimenta Ferrari

Papers

Oficinas de prevenção em um serviço de saúde para adolescentes: espaço de reflexão e de conhecimento compartilhado

Adolescents: knowledge about sexuality before and after participating in prevetion workshops

Healthcare for adolescents: perceptions by physicians and nurses in family health teams

Adolescencia: acciones y percepción de los médicos y enfermeros del Programa Salud de la Familia

Pré-natal: preparo para o parto na atenção primária à saúde no sul do Brasil